Churchill Retirement Assisted Living

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 residents' right to be treated with dignity and respect for 2 of 2 sampled residents (#s 2 and 8) and multiple unsampled residents who resided in MC1, one of the facility’s memory care units, and ate their meals in the dining room. Findings include, but are not limited to: The facility was comprised of an assisted living community and two memory care communities: MC1 and MC2. Observations of MC1 dining room were made on 04/14/26 and the following was identified: a. At 11:12 am, Resident 2 was observed sitting at a table in the dining room. The resident had two plates of food: a ham sandwich and a plastic cup of fruit on a ceramic plate, and scrambled eggs and toast on a paper plate. Resident 2 was drinking from a disposable cup. At 11:35 am, Staff 19 (CG) stated that staff used paper plates when residents needed their meals reheated. Staff 19 confirmed the kitchen gave disposable cups for all meals served in the memory care units. This was observed at 11:25 am when Staff 19 was pouring beverages for the lunch meal. A total of seven residents were observed using disposable cups at lunch. b. At 12:34 pm, Staff 19 began assisting Resident 8 with eating his/her lunch. The staff member was quiet and was not observed to talk with the resident while providing assistance. Resident 8 was sitting in a chair with his/her head bent down, keeping his/her eyes closed. Staff 19 stopped assisting Resident 8 at 12:37 pm, when an unsampled resident stated s/he wanted to go back to their apartment. At that time, Staff 19 turned her attention to the unsampled resident and stated, “You have to wait until everyone is finished with their dinner.” The staff member picked up the unsampled resident’s hearing device and stated, “You have to finish dinner.” The resident replied, “I can’t eat, I’m sick to my stomach.” Staff 19 began feeding the unsampled resident who was observed to wince when the utensil would get close to his/her mouth. The unsampled resident said, “I’ve got to go home.” Staff 19 continued to try to feed the resident and then asked, “Are you okay?” The resident replied, “No, I want to go to bed.” Staff 19 told him/her, “Just wait a few minutes for the food to go down”, and gave the resident a bite of food. Staff 19 got up from the dining room table and walked out of the dining room. The unsampled resident was assisted to his/her apartment by Staff 27 (MT) at approximately 1:10 pm. When Staff 19 returned to the dining room, she started cleaning up. Resident 8 had not been assisted to eat by any other staff member and had not attempted to get anything to eat or drink independently since 12:34 pm. At 1:03 pm, Staff 19 took the resident’s plate and put it in the microwave. A paper plate was not used to re-heat the meal as she reported was the process previously. Staff 19 continued to assist Resident 8 to eat at 1:04 pm. Twenty-six minutes passed while the resident sat at the dining room table and waited for someone to continue to assist with the remainder of his/her lunch. At 1:04 pm, when Staff 19 sat next to Resident 8, she did not announce herself. The staff member put food on a fork and touched the resident’s lips with the utensil. Resident 8 was visibly startled and stated, “Oh!” Staff 19 giggled. The need to ensure residents’ right to be treated with dignity and respect was reviewed with Staff 1 (Administrator), Staff 2 (ED), Staff 3 (RN), and Staff 6 (RN Consultant) on 04/16/26 at 3:40 pm. They acknowledged the findings.

1. Correction: Dining practices were corrected. Staff were re-educated on announcing presence, engaging throughout feeding, and timely assistance and overall dignity in the dining room. Disposable dishware discontinued unless clinically indicated. 2. System Fix: A Dining Dignity Protocol was implemented requiring engagement, proper communication, and supervision during meals and overall dignity practices. 3. Monitoring: 3x weekly x4 weeks, then monthly, using dining room observation dining tool. 4. Responsible Party: Administrator Resident Care Coordinator Food 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 ensure incidents of abuse or suspected abuse were immediately reported to the local Department office for 1 of 1 sampled resident (# 2) who was reviewed for suspected abuse, and failed to ensure injuries of unknown cause were immediately investigated by the facility, and if the investigation could not reasonably rule out abuse, the local Department office was notified for 1 of 2 sampled residents (# 2) who were reviewed for injuries of unknown cause. Findings include, but are not limited to: Resident 2 moved into one of the facility’s memory care communities in 09/2025 with diagnoses including mild cognitive impairment. The resident’s clinical record, dated 01/04/26 through 04/13/26, was reviewed and the following was identified: a. The following incidents of suspected abuse were documented: * An incident report dated 02/27/26 identified that another resident told staff that Resident 2 had been sexually assaulted by a male caregiver; and * An incident report dated 03/19/26 reported that Resident 2 stated, "[s/he] did not want to sleep with 'him' again referring to a caregiver." On 04/15/26 at 4:15 pm, Staff 1 (Administrator) and Staff 2 (ED) confirmed that neither incident had been immediately reported to the local Department office. Documentation of the incident dated 02/27/26 showed that the caregiver was put on leave until the facility conducted an investigation. Staff interviewed both Resident 2 and his/her family relating to the incident dated 03/19/26. Documentation showed that the resident began talking about a time when s/he lived in California. Documentation that the facility notified the local Department office of the 02/27/26 and 03/19/26 incidents of suspected abuse was provided on 04/15/26 at 6:12 pm. b. The following injuries were identified: * A progress note dated 03/05/26 identified the resident had a “small wound on the top of [his/her left] ?? what .” On 03/07/26 staff noted that Resident 2 did not know how s/he obtained the wound; and * A progress note dated 03/21/26 identified the resident had a scratch to the back of the heal. There was no documented evidence the facility had conducted an immediate investigation of the injuries to rule out abuse or suspected abuse. There was no documented evidence the facility had reported the injuries of unknown case to the local Department office. Documentation that the facility notified the local Department office of the injuries of unknown cause was provided on 04/17/26 at 10:03 am. The need to ensure incidents of abuse or suspected abuse were immediately reported to the local Department office and to ensure injuries of unknown cause were immediately investigated by the facility, and if the investigation could not reasonably rule out suspected abuse, the local Department office was notified was discussed with Staff 1, Staff 2, Staff 3 (RN), and Staff 6 (RN Consultant) on 04/16/26 at 3:40 pm. They acknowledged the findings.

1. Correction: Resident #2 the event was reported to appropriate authorities; full investigations completed and documented. 2. System Fix: Mandatory reporting training reinforced with clear immediate reporting expectations. 3. Monitoring: New Incident Reports and Progress Notes to be reviewed by Interdisciplinary Team daily in Clinical Meeting. 4. Responsible Party: Administrator, Licensed Nurses, Resident Care Coordinator.

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 reflective of resident care needs and preferences, provided clear direction to staff regarding the delivery of services, including a written description of who should provide the services and what, when, how, and how often the services shall be provided, were implemented, and/or were readily available to staff for 4 of 7 sampled residents (#s 1, 2, 6, and 8) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 6 moved into the assisted living community in 11/2023 with diagnoses including?bipolar disorder and type 2 diabetes mellitus. During the acuity interview on 04/13/26 Staff 3 (RN) and Staff 26 (MT) reported that service plans available to staff for assisted living residents were stored in a binder in a cabinet at the caregiver station in the middle of the unit on the second floor. At 3:30 pm on 04/13/26 the surveyor found a service plan for Resident 6 dated 09/11/25 in the Service Plan binder. On 04/14/26 at 9:30 am Staff 1 (Administrator) provided a copy of the resident’s most recent service plan, dated 03/07/26, which she endorsed had just been printed. Resident 6’s service plan available to staff and the current service plan were reviewed, observations were made, and interviews with staff and the resident were conducted. The service plan available to staff was not reflective of the resident’s needs, and did not provide clear direction to staff in the following areas: * Transferring and sit-to-stand use; * Incontinence care; * Mobility; * Safety checks; and * Behaviors related to sit-to-stand lift refusals. Caregivers throughout the survey reported varied understanding regarding what Resident 6 required for transferring, and whether a sit-to-stand lift was required for safety or was offered to the resident based on his/her preference. In an interview on 04/16/26 at approximately 2:30 pm Staff 4 (RCC) reported that her understanding of the resident’s needs was that the sit-to-stand lift use for Resident 6 was a safety requirement, and that caregivers had been instructed to not transfer the resident if s/he refused to use the lift. On 04/16/26 at 1:00 pm, the need to ensure service plans were reflective of the residents’ needs, provided clear direction to staff, and were implemented, was discussed with Staff 1, Staff 2 (ED), Staff 3 (RN), and Staff 6 (RN Consultant). They acknowledged the findings. 2. Resident 1 moved into one of the facility’s memory care communities in 04/2025 with diagnoses including?Alzheimer’s disease. The resident’s 03/05/26 service plan was reviewed and the following was identified: a. The following was not reflective of the resident’s current care needs: * Sleeping routines; * Eating routines; * What services hospice provides; * Meal assistance; and * Resident's need for dentures during mealtimes. b. There was conflicting information relating to how often staff were to provide safety checks. c. Toenail care was not being implemented. Resident 1’s 03/05/26 service plan reflected staff were to preform toenail care “after each bath/shower.” On 04/15/26 at 11:12 am, the resident exited his/her apartment and was observed to not have socks or shoes on. Resident 1’s toenails were long and appeared to be approximately ¾ of an inch longer than the end of his/her toes. Staff 17 (CG) said she thought that a podiatrist cut the resident’s toenails. On 04/16/26 at 12:50 pm, Staff 21 (CG) confirmed that staff were to cut Resident 1’s toenails but they only had small fingernail clippers and she needed the large toenail clippers. Staff 21 stated she did not use the small clippers as she “didn’t want to hurt [the resident].” The need to ensure service plans were reflective of the residents’ current needs and preferences, provided clear direction to staff, and were implemented was discussed with Staff 1 (Administrator), Staff 2 (ED), Staff 3 (RN), and Staff 6 (RN Consultant) on 04/16/26 at 3:40 pm. They acknowledged the findings. 3. Resident 2 moved into one of the facility’s memory care communities in 09/2025 with diagnoses including mild cognitive impairment. The resident’s 03/30/26 service plan was reviewed and the following was identified: a. The following was not reflective of the resident’s current care needs: * The use of glasses; * Eating in the dining room; * Toileting assistance; * Sleep schedule and the need to provide snacks during the night hours; * Behavior interventions; and * Transfer assistance. On 04/14/26, Resident 2 was observed to not wear glasses, to eat meals in both the dining room and in his/her apartment, and transfer independently. b. There was conflicting information relating to the following: * The service plan reflected Resident 2 was receiving PRN psychotropics, but MARs, dated 03/01/26 through 04/13/26, reflected a scheduled psychotropic medication; and * The information in the service plan reflected the resident’s desire to lose weight, but the resident had documentation beginning on 01/04/26 of a significant weight loss and interventions had been implemented for Resident 2 to gain weight. c. The following was not being implemented: * Nutritional shakes with lunch and dinner; * Interventions for the resident's suicidal ideations; and * The resident requiring only female caregivers. On 04/14/26 at 12:29 pm, Staff 19 (CG) prepared a room tray for Resident 2. There was no nutritional shake brought to the unit from the kitchen, and Staff 19 did not include a nutritional shake when giving the resident his/her lunch in the resident’s apartment. On 04/16/26 at 9:59 am, Staff 10 (Lead Cook) and Staff 11 (Cook) verified that although they were aware that Resident 2 needed nutritional shakes with lunch and dinner, they were not aware s/he moved from MC2 to MC1 on 03/20/26. They continued to send the shakes to MC2. Progress notes, dated 02/12/26 through 04/10/26, identified two separate times when Resident 2 experienced suicidal ideations. A Temporary Service Plan was implemented on 02/12/26 to direct staff on how to care for the resident when this occurred. The information was not transcribed onto the 03/30/26 service plan. The intervention of having female only caregivers was documented on an incident report dated 03/19/26. This information had not been transcribed onto Resident 2’s 03/30/26 service plan. On 04/16/26 at 10:12 am, Staff 27 (MT) stated that both male and female caregivers could work with Resident 2. d. The service plan was not readily available to staff. Per acuity interview on 04/13/26, staff reported that the residents’ service plans who resided in MC1 were located in a cupboard in the dining room. On 04/14/26 at 11:59 am, Staff 19 (CG) told Staff 29 (MT), “I don’t have a key to this,” while pointing to a cupboard in MC1’s dining room. Staff 29 tried to open the cupboard with a couple of keys but was unable to unlock it. At 12:06 pm, Staff 19 confirmed the residents’ service plans were in the locked cupboard in the dining room and stated the reason why the cupboards were locked was because there were hot chocolate packets that the staff did not want the residents “to get into.” However, the cupboard where the hot chocolate packets were located was observed to be unlocked. At 12:07 pm, Staff 29 unlocked the cupboard and placed the service plan binder on a table where other binders were located in the unit’s dining room. Staff 29 confirmed that only MTs had keys and if a MT was not on the unit, CGs would have to use the walkie-talkie to request a MT to open the cupboard. The need to ensure service plans were readily available to staff, reflective of the residents’ current needs and preferences, provided clear direction to staff, and were implemented was discussed with Staff 1 (Administrator), Staff 2 (ED), Staff 3 (RN), and Staff 6 (RN Consultant) on 04/16/26 at 3:40 pm. They acknowledged the findings. 4. Resident 8 moved into one of the facility’s memory care communities in 11/2023. On 04/14/26 at 11:43 am, Staff 29 (MT) brought Resident 8 into the dining room and Staff 19 (CG) helped the resident to sit at the table saying, “Come on, Grandma.” Staff 19 confirmed the resident was not her grandparent but was told that Resident 8 preferred to be addressed by “Grandma”. On 04/16/26 at 10:06 am, both Staff 12 (CG/Front Desk) and Staff 27 (MT) confirmed Resident 8 preferred to be called “Grandma”. Staff 12 reported that the resident responded better by smiling and engaging when s/he was referred to as “Grandma”. She stated that Resident 8 was more serious when staff called him/her by their official name. There was no direction to staff relating to the resident’s preferred name in Resident 8’s 03/24/26 service plan. Staff 27 reviewed the resident’s service plan and confirmed there was no direction to staff to call the resident “Grandma”. She reported that if Resident 8’s family was visiting and staff did not call the resident “Grandma” they would correct staff and say, “[S/he] would really like it if you called [him/her] Grandma.” The need to ensure service plans were reflective of the resident’s current needs and preferences and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (ED), Staff 3 (RN), and Staff 6 (RN Consultant) on 04/16/26 at 3:40 pm. They acknowledged the findings.

1. Correction: Resident #1, #2, #6, #8 have been reviewed by the Interdisciplinary Team to ensure their service plans reflect the resident’s current care needs and provide clear direction regarding delivery of services for all areas of care. 2. System Fix: Resident service plans will be reviewed and updated at their next evaluation to ensure the service plans are reflective of each resident’s care needs and provide clear direction to staff for the provision of care. Education provided to staff on Service Plan and Temporary Service Plan process. 3. Monitoring: Interdisciplinary Team will review that the service plans are being updated quarterly and when there is a change in condition. Audit details to be reported at Quarterly QA meeting. 4. Responsible Party: Administrator, Resident Care Corrdinator, Licensed Nurses

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

Based on observation, interview, and record review, it was determined the facility failed to ensure resident-specific actions or interventions were determined, documented, communicated to staff on each shift, and were monitored at least weekly until the condition resolved for 2 of 6 sampled residents (#’s 2 and 4), who were reviewed for changes of condition. The findings include, but are not limited to: 1. Resident 4 moved into the assisted living in 01/2023 with diagnoses including chronic Stage 3 kidney disease, hypertension, and edema. The resident’s clinical record from 01/13/26 through 04/13/26 was reviewed during the survey. The following short-term changes of condition were identified: On 3/23/26 the following medications were discontinued: * Saccharomyce S Boul 250 mg capsule (for acid reflux); * Triamcinolone cream (for dermatitis); * Cetirizine HCL 10 mg tablet (for allergies); * Duloxetine 60 mg capsule (antidepressant); * Magnesium Oxide 400 mg tablet (restless legs); * Omeprazole 20 mg capsule (for acid reflux); * Ropinirole 5 mg tablet (for restless legs); and * Valsartan 80 mg tablet (for hypertension and blood pressure). There was no documented evidence the facility determined actions or interventions needed, communicated actions or interventions to staff on each shift and monitored the resident following discontinuation of the above medications or treatments. The need to ensure the facility determined actions or interventions, communicated the action or intervention to staff on each shift and monitored the change of condition at least weekly until the condition resolved was discussed with Staff 1 (Administrator), Staff 2 (ED), Staff 3 (RN) and Staff 6 (RN Consultant) on 04/16/26 at 2:35 pm. They acknowledged the findings. 2. Resident 2 moved into one of the facility’s memory care communities in 09/2025 with diagnoses including mild cognitive impairment. The resident’s clinical record, dated 01/04/26 through 04/13/26, was reviewed and the following short-term changes of condition were identified: * An incident report dated 03/19/26 reported that Resident 2 stated, "[s/he] did not want to sleep with 'him' again referring to a caregiver"; and * In a progress note dated 04/09/26, staff reported the resident fell. There was no documented evidence the facility determined actions or interventions needed, communicated those actions or interventions to staff on each shift, and monitored the resident through resolution. The need to ensure the facility determined actions or interventions, communicated the action or intervention to staff on each shift and monitored the change of condition at least weekly until the condition resolved was discussed with Staff 1 (Administrator), Staff 2 (ED), Staff 3 (RN) and Staff 6 (RN Consultant) on 04/16/26 at 3:40 pm. They acknowledged the findings.

1. Correction: Residents #2 & #4 short term condition changes will be recapped by the Licensed Nurse to ensure issues have been resolved and no furter actions/interventions are needed. Service Plans will updated as needed. 2. System Fix: Change in Residents condition will be monitored and identfied through the 24-hour chart review and follow-up process. During morning clinical meeting the clinical team will review short term change of condition and determine approprite actions/interventions and will use the temporary serivce paln process to communicate the Residents needs to staff for monitoring. Licensed Nurse will monitor short term change of condition weekly for needs and resolution. 3. Monitoring: Change in resident’s acute condition will be monitored and identified through the 24-hour chart review and follow-up process. Acute Changes in conditions will also be discussed at morning clinical meetings to determine any need for Licensed Nurse weekly notes. Weekly Audit x2, then Monthly 4. Responsible Party: Administrator, Licensed Nurses, Resident Care Coordinator

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(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs.

Based on interview and record review, it was determined the facility failed to coordinate care with on-site healthcare providers, including ensuring staff were informed of new interventions and the service plan adjusted for 1 of 1 sampled resident (#6) who received services from an outside behavior support services provider. Findings include, but are not limited to: Resident 6 moved into the assisted living community in 11/2023 with diagnoses including bipolar disorder and type 2 diabetes mellitus. Review of the resident’s progress notes, dated 01/15/26 through 04/13/26, identified the resident received behavior support services on-site from an outside provider. On 04/15/26 at 8:45 am the surveyor requested all behavior professional (BP) notes from the last 90 days. On 04/16/26 at 8:55 am Staff 1 provided a BP note dated 03/19/26. No other documentation was provided. The progress notes documented visits from the BP on 03/22/26, 03/26/26, and 04/07/26, which included the following recommendations and comments: * 03/26/26 – “Behavioral health saw resident and recommended when trying to get resident to get up to get [his/her] briefs changed or trying to toilet [him/her] that we don’t tell [him/her] [s/he’s] ‘supposed to’ or that it will be a refusal if [s/he] doesn’t because that will make[him/her] more defensive and more likely to refuse care in the future. They recommend being patient and letting [him/her] know we are doing it because we care about [him/her].” * 04/07/26 – “LPN, RN, Admin [Administrator] unavailable to speak with today. BP would like to talk about concerns Re [regarding]: chronic UTI [urinary tract infection]/hygiene, and the sit-to-stand issue.” There was no documented evidence the facility informed staff of new interventions, that the service plan was adjusted as required. These findings were reviewed with Staff 1, Staff 2 (ED), Staff 3 (RN), and Staff 6 (RN Consultant) on 04/16/26 at 1:00 pm. They acknowledged the need for the facility to coordinate care with on-site healthcare providers.

1. Correction: Resident #6 had a Temporary Service Plan created to ensure implementation of recommendations from outside provider and was added to Service Plan. 2. System Fix: Resident visits from outside providers to go through triple check process, to ensure recommendations implemented. 3. Monitoring: Wellness Director or designee will review all Outside Provider visit notes to ensure recommendations are initiated on appropriate TSP for staff review and signatures. 4. Responsible Party: Administrator, Licensed Nurse, Resident Care Corrdinator

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs.

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

Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment for several unsampled residents. Findings include, but are not limited to: 1. On 04/15/26 at 2:30 pm, Staff 25 (MT) was observed counting medications with another MT who removed oral medications from multiple medication bottles, touching the oral medications with her bare hands and painted fingernails. The need to ensure MT’s maintained infection prevention and control protocols during medication administration was discussed with Staff 1 (Administrator), Staff 2 (ED) and Staff 6 (RN Consultant) on 04/16/26 at approximately 5:00 pm. They acknowledged the findings. 2. The facility was comprised of an assisted living facility and two memory care communities referred to as MC1 and MC2. The following was identified during meal service: a. On 04/14/26 at 11:35 am, Staff 19 (CG) was observed getting the MC1 dining room ready for lunch which included setting out silverware and napkins, and filling cups with beverages and placing them onto the tables. There was no hand hygiene or donning gloves observed prior to Staff 19 touching the items and she was not wearing an apron, over her potentially contaminated clothing. In addition, Staff 19 was touching her face and hair and carrying the cups by the top, where residents would be drinking from. At 12:27 pm, Staff 19 and Staff 29 (MT) was observed serving lunch to residents in the MC1 dining room. It was confirmed that both staff member provided personal care to residents. Neither staff member was observed wearing an apron over there potentially contaminated clothing or performing hand hygiene. At 12:34 pm, both Staff 19 and Staff 29 donned aprons and gloves. Six residents had already been served their lunch in the dining room prior to staff donning the aprons and gloves. At approximately 12:30 pm, while Staff 19 was cutting an unsampled resident’s food, the resident’s hearing device fell to the dining room floor. The staff member picked it up, placed it on the table and continued to cut the food. There was no hand hygiene observed between picking the device up and resuming cutting the resident’s food. Immediately after cutting up the unsampled resident’s lunch, Staff 19 was observed taking four lunch plates and all of the desserts out of the insulated food cart, uncovered all of the food, and placed it on a utility table to the left of a cupboard. She placed a lunch plate, condiments, beverage and a dessert on a plastic tray. Staff 19 carried the tray down the hall and delivered it to a resident’s apartment. She did not place a covering on any of the items prior to transporting the tray from the dining room to the resident’s apartment. Three of the plates continued to be uncovered until 1:32 pm, approximately one hour, when the surveyor exited the unit. There were no observations made of the food being re-covered or discarded. b. On 04/16/26 at 12:50 pm in the kitchenette located on MC2, there were three dishes of beef, rice, vegetables, and multiple dishes of dessert observed sitting uncovered on the counter. There were three CGs observed in the dining area. One CG was assisting an unsampled resident with lunch, wearing gloves but no apron over her potentially contaminated clothing. At 12:55 pm, she entered the kitchenette to cover the remaining dishes of lunch and put them in the refrigerator. No hand hygiene was observed. Staff 21 (CG) was observed in the kitchenette, not wearing an apron over her potentially contaminated clothing. The need to ensure caregiving staff maintained infection prevention and control protocols during meal times was discussed with Staff 1 (Administrator), Staff 2 (ED), Staff 3 (RN), and Staff 6 (RN Consultant) on 04/16/26 at 3:40 pm. They acknowledged the findings.

1. Correction: Staff retrained on infection control standards regarding medication handling and food safety. 2. System Fix: Staff retrained on infection control standards including medication handling and food safety. 3. Monitoring: Weekly dining and med pass rounds x4 weeks, then monthly. RN Consultant to provide monthly audit of IP practices in the dining room and during med pass. Infection control standards related to med pass will be monitored by pharmacy during quarterly visit. 4. Responsible Party: Administrator, Licensed Nurses, Resident Care Coordinator, Nurse Consultant Pharmacy

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

OAR 411-054-0055 (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 orders were carried out as prescribed, and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer for 2 of 6 sampled residents (#s 1 and 4) whose orders were reviewed. The findings include, but are not limited to: 1. Resident 4 moved into the assisted living in 01/2023 with diagnoses including chronic stage 3 kidney disease, hypertension, and edema. The resident’s current orders and MARs from 03/01/26 through 04/13/26 were reviewed during the survey. a. The following medications were not carried out as prescribed: * Potassium Chloride 10 mEq ER tablet was not administered from 03/24/26 - 03/30/26; * Cyclobenzaprine 5mg tablet, take one tablet twice per day for muscle spasms was not administered from 04/10/26 (second dose) - 04/13/26; * Lidocaine Patch daily for pain was not administered from 04/10/26 -04/13/26; * Polyethylene glycol take 17 gm daily for bowel care was not administered 04/10/26-04/13/26; * Senna 8.6 mg tablet, take one tablet, twice per day for bowel care was not administered from 04/10/26 -04/13/26; * Pregabalin 50 mg capsule take three times per day was not administered 04/10/26 (third dose) - 04/13/26; * Ropinirole tablet 1 mg tablet at bedtime for restless legs was not administered from 04/10/26 -04/13/26; and * Trazadone 50 mg, an antidepressant, give one tablet at bedtime was not administered from 04/10/26 -04/13/26. b. There were no signed physician or other legally recognized practitioner orders in the resident’s facility record for the following medications: * Oxycodone 5 mg tablet, take one tablet three times per day; * Tylenol 325 mg take two tablets every four hours ,as needed for pain; * Albuterol HFA inhaler every four hours, as needed for shortness of breath; * Antacid Suspension take two tablespoons by mouth every six hours, as needed, for stomach upset; * Fleet glycerin Suppository 2 gm daily, as needed, for bowel care; and * Naloxone HCL Spray for suspected opiate overdose, as needed. The need to ensure physician orders were carried out as prescribed, and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer was discussed with Staff 1 (Administrator), Staff 2 (ED), Staff 3 (RN) and Staff 6 (RN Consultant) on 04/16/26 at 2:35 pm. They acknowledged the findings. 2. Resident 1 moved into one of the facility’s memory care unit in 04/2025 with diagnoses including?Alzheimer’s disease and was admitted onto hospice services on 04/07/26. The resident’s clinical record, including MARs, physician’s orders, and progress notes were reviewed during the survey. The surveyor requested signed physician’s orders on 04/16/26 at 9:27 am. At 11:02 am, signed orders were received but per the documentation on the orders, the facility received them via fax on 04/16/26 at 10:33 am, during the time of the survey. There was no documented evidence the facility had written, signed physician or other legally recognized practitioner orders in the resident’s facility record for all medications and treatments the facility was responsible to administer. The need to ensure the facility had written, signed physician or other legally recognized practitioner orders in the resident’s record for all medications and treatments the facility was responsible to administer was discussed with Staff 1 (Administrator), Staff 2 (ED), Staff 3 (RN) and Staff 6 (RN Consultant) on 04/16/26 at 3:40 pm. They acknowledged the findings.

1. Correction: Orders were clarified with Physician and implemented correctly for residents #1 & #4. 2. System Fix: Medication orders will go through a triple check process and will be brought to daily clinical meeting. A review of the orders portal in Point Click Care for any new or discontinued orders will be completed by . Interdisciplinary Team Medication orders will be verified with signed orders in house. 3. Monitoring: Weekly medication orders audits x4 weeks, then monthly. 4. Responsible Party: Licensed Nurse.

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 (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 kept accurate and included resident-specific parameters for PRN medications for 1 of 6 sampled residents (# 2) whose medications were reviewed. Findings include, but are not limited to: Resident 1 moved into one of the facility’s memory care community in 04/2025 with diagnoses including?Alzheimer’s disease. The resident’s clinical record including MARs, dated 04/01/26 through 04/13/26, and physician’s orders were reviewed during the survey. The following inaccuracies were identified: a. The following PRN medications were transcribed onto the MAR without current orders for administration: * Acetaminophen (for pain); * Barrier cream (for skin); * Polyethylene glycol (for constipation) to administer for no bowel movement in three days; * Polyethylene glycol to be administered for no bowel movement in five days; * Antacid (for upset stomach); * Hydrocodone (for pain); * Loperamide (for diarrhea); and * Ondansetron (for heart burn). b. The following PRN bowel medications used for constipation lacked instruction to staff on the sequential order of administration: * Polyethylene glycol, once daily; and * Senna, twice daily. The need to ensure MARs were accurate and included resident-specific parameters for PRN medications was discussed with Staff 1 (Administrator), Staff 2 (ED), Staff 3 (RN) and Staff 6 (RN Consultant) on 04/16/26 at 3:40 pm. They acknowledged the findings.

1. Correction: Resident #1 MARs were reviewed and orders were clarified to include PRN parameters. 2. System Fix: During Morning clinical meeting Interdisciplinary Team will review orders pending through the portal. LN or designee will follow-up until orders can be confirmed. 3. Monitoring: Weekly MAR audits x4 weeks, then monthly. Pharmacy Consultant or designee will audit for resident specific instructions/parameters during their quarterly audit. 4. Responsible Party: Administrator Licensed Nurses Resident Care Coordinator.

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 411-054-0070 (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.

Based on observation and record review, it was determined the facility failed to have two direct care staff scheduled and available at all times whenever a resident required the assistance of two direct care staff for scheduled and unscheduled needs. Findings include, but are not limited to: The facility was divided into three distinct and segregated areas: two memory care units, Memory Care 1 and Memory Care 2, and an assisted living unit on the second floor. At the time of the survey, the facility was home to 69 residents: 16 in Memory Care 1, nine in Memory Care 2, and 44 in the assisted living unit. Documentation provided by the facility on 04/14/26 indicated that one resident in Memory Care 2 and one resident in the assisted living unit required multiple-person transfers. The facility’s posted staffing plan identified the night shift, 10:30 pm to 6:30 am, was staffed with four direct care staff: one caregiver in each of the memory care units, one care giver in the assisted living unit, and one medication aide that floated between the three units. The facility failed to have a minimum of two direct care staff available in each of the units where a resident required the assistance of two direct care staff for scheduled and unscheduled needs. These findings were discussed with Staff 1 (Administrator) on 04/15/26 at 8:45 am. She acknowledged the findings.

1. Correction: Staffing assignments corrected to ensure adequate staffing for night shift for individuals who require the assistance of 2 direct care staff. 2. System Fix: All shifts reviewed, and scheduling safeguards implemented to ensure adequate staffing when residents in an area may require the assistance of 2 direct care staff. 3. Monitoring: Daily staffing review x60 days. 4. Responsible Party: Administrator Resident Care Coordinator

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.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C200, C231, C295, and C360.

See Plan of Correction for C200, C231, C295 and C360

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility.

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C260, C270, C303, and C310.

See Plan of Correction for C260, C270, C303 and C310

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility.

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities.

Based on observation, interview, and record review, it was determined the facility failed to evaluate the resident for activities and develop an individual activity plan based on their activity evaluation, for 3 of 4 sampled residents (#s 1, 2, and 8) whose activity plans were reviewed. Findings include, but are not limited to: During the survey, sampled and unsampled residents were observed needing assistance and encouragement from staff to initiate, attend, and participate in activities. The facility offered group activities, which many residents attended. Some residents did not attend the activities and, instead, stayed in their rooms, sat in the common areas, or ambulated in the unit. Resident 1, 2, and 8’s service plans were reviewed, and observations were made of the residents. The following was identified: Though the service plan included some information about activity preferences, there was no documented evidence of an evaluation that addressed the following required elements: * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Identification of activities for behavioral interventions. On 04/16/26 at 10:16 am, Staff 8 (Activities Lead) verified neither she nor her staff had evaluated the residents who resided in the two memory care units as it pertained to activities. She also confirmed that an individual activity plan had not been developed. The need to develop individualized activity plans that were based on a thorough evaluation of the resident's activity interests, abilities, and needs was discussed with Staff 1 (Administrator), Staff 2 (ED), Staff 3 (RN) and Staff 6 (RN Consultant) on 04/16/26 at 3:40 pm. They acknowledged the findings.

1. Correction: Individualized activity plan evaluation have been completed for resident's #1, #2, & #8. to ensure that they are appropriate for their activity preferences. 2. System Fix: Resident Service Plans/ Activity Plans will be reviewed and updated at their next evaluation to ensure the Service Plans are reflective of each resident’s activities needs and provide clear direction to staff for the provision of personalized activities. Education provided to staff on service planning and providing individualized activities in Memory Care. Activities Evaluation section updated in Point Click Care to ensure individualized activity plans for each resident. Will complete each resident upon next evaluation. 3. Monitoring: Interdisciplinary Team to review for accuracy after each resident evaluation is completed. 4. Responsible Party: Interdisciplinary Team including Activities Coordinator

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities.

OAR 411-054-0025 (7) Facility Administration: Policy & Procedure (7) POLICIES AND PROCEDURES. The facility must develop and implement written policies and procedures that promote high quality services, health and safety for residents, and incorporate the community based care principles of individuality, independence, dignity, privacy, choice, and a homelike environment. The facility must develop and implement: (a) A policy on the possession of firearms and ammunition within the facility. The policy must be disclosed in writing and by one other means of communication commonly used by the resident or potential resident in his or her daily living. (b) A written policy that prohibits sexual relations between any facility employee and a resident who did not have a pre-existing relationship. (c) Effective methods of responding to and resolving resident complaints. (d) All additional requirements for written policies and procedures as established in OAR 411-054-0012 (Requirements for New Construction or Initial Licensure), OAR 411-054-0040 (Change of Condition and Monitoring), OAR 411-054-0045 (Resident Health Services), and OAR 411-054-0085 (Refunds and Financial Management). (e) A policy on smoking. (A) The smoking policy must be in accordance with: (i) The Oregon Indoor Clean Air Act, ORS 433.835 to 433.875; (ii) The rules in OAR chapter 333, division 015; and (iii) Any other applicable state and local laws. (B) The facility may designate itself as non-smoking. (f) A policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner. The policy must include information regarding the collection of medical and forensic evidence that must be obtained within 86 hours of the incident. (g) A policy on facility employees not receiving gifts or money from residents. (h) Protocols for preventing and controlling infection, as described in OAR 411-054-0050. (i) LGBTQIA2S+ Nondiscrimination Notice: “(Name of care facility) does not discriminate and does not permit discrimination, including but not limited to bullying, abuse or harassment, based on an individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status, or based on an individual’s association with another individual on account of the other individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status. If you believe you have experienced this kind of discrimination, you may file a complaint with the Oregon Department of Human Services at (provide current contact information).” (j) ABST Policy for accurate and consistent implementation of the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs.

Based on observations, interviews, and record review, it was determined, the facility failed to ensure there was an effective method in place to respond and resolve resident complaints related to food/meal service. Findings include but are not limited to: On 03/03/25 at 9:30 am, food complaints and resident council minutes were reviewed. The following was identified: *January’s minutes noted residents complained of running out of items they liked such as cereal, silverware, cups and glasses; *February’s minutes noted residents were having trouble getting things cut up per their request/care plan and that some residents “get the impression the kitchen staff does not take their concerns seriously and just dismiss them entirely as change is very slow to come;” and *On 02/16/25 residents noted lunch was “cold” and of poor quality. On 03/03/25 at 10:45 am, Resident 1, Resident Council President, was interviewed and stated the following: *Food was always/mostly cold and never “hot”; *Meat was often tough/dry and hard to eat; *Residents did not like the menus; *Quality of the food was not acceptable; *Menu items would change without notification; *Room trays were often not what was ordered or not cut up per resident need; and *The residents did not feel heard related to on-going food concerns. During the lunch meal on 03/03/25 from 12:00 to 12:45pm 13 residents were observed eating in the dining room. Eleven residents were interviewed regarding the food. Seven of the 11 indicated some or all of the following: *Meals are “always” cold; and *Meat was often tough and dry; and *Disliked the “Grove” menus; and *Disliked the couscous. Three of the residents stated the lunch the day before was “gross”. One of the residents commented that many times the food “inedible.” Majority of residents interviewed indicated they did not have adequate input into menu choices. During the lunch observation on 03/03/25, test trays were requested. The macaroni and cheese was observed at 112 degrees and tasted luke warm. Broccoli was observed at 103 degrees and tasted cold. Soup was observed at 109 degrees and tasted cold. Toasted garlic bread was observed at 100 degrees and tasted cold. Roasted chicken breast was observed at 117 degrees and tasted luke warm and was noted to taste dry. A cheeseburger patty was noted at 137 degrees and tasted warm and the meat was dry. The test trays were noted to be not palatable. During an interview on 03/03/05, at 1:15 pm, Staff 2 (Food Service Director) stated the following: *Meal delivery to the rooms had recently changed to help with cold food concerns; *Changed food prepared in main kitchen to improve consistency and quality; *Food was being delivered to the south dining room in tin foil and saran wrap; *Insulated carts were not used in delivery. During an interview on 03/03/05 at 3:00pm, Staff 1 (Administrator), Staff 2 and Staff 3 (Executive Director) acknowledged the on-going concerns related to food quality and temperature from the residents. On 04/04/25 at 1:30 pm Resident 2 was interviewed. The resident stated they needed their food cut up related to missing/pulled teeth and had communicated it to facility staff. Resident 2 stated they were not receiving cut up foods. Resident #2 service plan was reviewed and did not indicate need for food cut up. The facility had a list of residents who requested food cut up in the dining room posted for staff. Resident #2 was not on the list. Residents interviewed continue to feel the food service at facility was not adequate. Observations during meal service validated unpalatable temperatures for many food items. The facility has not effectively responded to or resolved concerns/complaints regarding meal services.

A)South Kitchen and Memory kitchenettes areas of note added to kitchen cleaning task sheet, staff training was completed to ensure cleaniness of idenified areas. B)Maintance to repair areas of note listed in Statement of deficencys C)Proper coverage of food items with proper dating, Food to be disposed of within 5 days. D)A thermometer was placed in all refridgerators. Tempature logs implemented in kitchenettes to log and ensure temp is maintaned at or below 41*. This is to be montiored x1 weekly for 3 months Administrator or Designee E) Single serve items not stored in closed containers F) Aprons were provided to staff to use while serving meals to resident to prevent comtaimnation from care tasks to meal service. G) Beard nets & Jewelry addressed H) Temperature to be monitored by culinary director or designee to monitor x3 a week for 3 months and as needed. I) Separate food services meeting implemented to ensure feedback on quality of meals, temperature, accuracy of orders, menu input and any other resident’s needs, monthly. A resident satisfaction survey was implemented. All areas of concern will be looked at x1 weekly for two monthes than once monthly and as needed

OAR 411-054-0025 (7) Facility Administration: Policy & Procedure (7) POLICIES AND PROCEDURES. The facility must develop and implement written policies and procedures that promote high quality services, health and safety for residents, and incorporate the community based care principles of individuality, independence, dignity, privacy, choice, and a homelike environment. The facility must develop and implement: (a) A policy on the possession of firearms and ammunition within the facility. The policy must be disclosed in writing and by one other means of communication commonly used by the resident or potential resident in his or her daily living. (b) A written policy that prohibits sexual relations between any facility employee and a resident who did not have a pre-existing relationship. (c) Effective methods of responding to and resolving resident complaints. (d) All additional requirements for written policies and procedures as established in OAR 411-054-0012 (Requirements for New Construction or Initial Licensure), OAR 411-054-0040 (Change of Condition and Monitoring), OAR 411-054-0045 (Resident Health Services), and OAR 411-054-0085 (Refunds and Financial Management). (e) A policy on smoking. (A) The smoking policy must be in accordance with: (i) The Oregon Indoor Clean Air Act, ORS 433.835 to 433.875; (ii) The rules in OAR chapter 333, division 015; and (iii) Any other applicable state and local laws. (B) The facility may designate itself as non-smoking. (f) A policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner. The policy must include information regarding the collection of medical and forensic evidence that must be obtained within 86 hours of the incident. (g) A policy on facility employees not receiving gifts or money from residents. (h) Protocols for preventing and controlling infection, as described in OAR 411-054-0050. (i) LGBTQIA2S+ Nondiscrimination Notice: “(Name of care facility) does not discriminate and does not permit discrimination, including but not limited to bullying, abuse or harassment, based on an individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status, or based on an individual’s association with another individual on account of the other individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status. If you believe you have experienced this kind of discrimination, you may file a complaint with the Oregon Department of Human Services at (provide current contact information).” (j) ABST Policy for accurate and consistent implementation of the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs.

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

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair, in a sanitary manner, and ensure meals were palatable in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the south kitchen and memory care kitchenettes on 03/03/25 from 9:30 am through 2:30 pm and the Main kitchen on 03/04/25 from 9:30 am thru 2:30 pm revealed the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following: South Kitchen: * Floors under/behind/between equipment; * Ceiling Vents; * Sides of stove/grill; * Metal utility carts; * Non metal utility carts; * Table top and large mixers; * Blender base; * Flooring around entry/exit doors to kitchen/service area; * Flooring around corners/edges in serving area; * Edges of shelving on racks in walk in cooler; * Freezer floor and threshold from cooler to freezer; * Green food delivery carts; * Microwave in dining room; * Juice machine in dining room; * Industrial can opener and housing; and * Tall movable metal rack. MC unit 2: * Reach in larger refrigerator; * Metal service equipment (not used); and * Microwave. Main Kitchen area: * Floors corners, edges; * Floors in walk in cooler under metal racks; * Racks in dry storage; * Metal can rack; * Microwave; * Walls/floors under dish washing area; and * Industrial can opener and housing. b. The following areas were in need of repair: * South serving area with sections of the wall with damage/exposed drywall. * South reach in freezer had large accumulation of ice. * Ceiling section near hood with cracked/peeling paint/previous water damage. * Missing cove base in sections of door thresholds in south kitchen. * Convection oven not operational in south kitchen. * Main kitchen bakery prep table was separated and pulling away from the wall c. Food items observed stored in reach in freezer were uncovered. Items found in coolers/refrigerators were not dated when opened or prepared. Food items found that were past manufactures use by dates. Facility prepared food found past 7 days. Ice cream in Memory care unit 1 found in reach in freezer that was not frozen. d. Activities area refrigerator contained food items that were opened and not dated. Multiple packages of dry good foods were found stored in cupboards/cabinets that were not closed and open to potential contamination. Refrigerator storing resident food did not have a thermometer to ensure food was stored at or below 41 degrees as required. e. Reach in refrigerators in both unit kitchenettes were noted above 41 degrees. There was not a system in place for staff to monitor refrigerator temperatures to ensure food was stored at appropriate temperatures. Staff 1 and 2 acknowledged food was not stored at appropriate temperatures and would need to be discarded. e. Single service utensils and paper plates stored in dry storage open to potential contamination. f. Care staff assisting residents with meal service were not wearing aprons or protective outer clothing to prevent potential contamination from care tasks to meal service tasks. g. Staff member washing dishes did not have facial hair restrained as required. h. Multiple residents during meal observations complained that often food temperatures seemed cold. A test tray received at 12;00 pm noted multiple meal items were not palatable. Mac and cheese was observed at 112 degrees and tasted luke warm. Broccoli was observed at 103 degrees and tasted cold. Soup was observed at 109 degrees and tasted cold. Toasted garlic bread was observed at 100 degrees and tasted cold. Roasted chicken breast was observed at 117 degrees and tasted luke warm and was noted to taste dry. Cheeseburger patty was noted at 137 degrees and the meat was dry. i. Cook serving the meal was observed to have multiple bracelets on during meals service, which is not allowed per code. On 03/03/25 Food Service Director and Staff 3 (Executive director) toured areas with surveyor and acknowledged the areas identified. On 03/03/25 at 2:00 pm, surveyor discussed test tray findings with Staff 2, Staff 1 and Staff 3. Who acknowledged the findings and no additional information was provided.

1) The Culinary Director reassessed and ordered more needed items. 2) Resident service plan and Dietary cut up list updated to be reflective of resident’s new needs. 3) Training provided to cooks and servers on 3/17/25, New plate warmers implemented to ensure correct heating temperature. 4) The Separate food services meeting implemented to ensure feedback on quality of meals, temperature, accuracy of orders, menu input and any other resident’s needs, monthly. A resident satisfaction survey was implemented. 5) Transporting food, is now done in a heat containing cart. Temperature audit x3 weekly for one month and ongoing as needed. The Administrator and Culinary Director will be responsible for overseeing this.

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 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

Based on observations and interviews, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240.

Refer to C154 and C240

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

OAR 411-054-0025 (5) Facility Administration: Required Postings (5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following: (a) Facility license. (b) The name of the administrator or designee in charge. The designee in charge must be posted by shift or whenever the administrator is out of the facility. (c) The current facility staffing plan. (d) A copy of the most recent re-licensure survey, including all revisits and plans of correction as applicable. (e) The Ombudsman Notification Poster. (f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections. (g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted. (h) Other notices relevant to residents or visitors required by state or federal law.

Based on observation and interview, it was determined the facility failed to ensure required postings were in a routinely accessible and conspicuous location to residents and visitors. Findings include, but are not limited to: The facility was toured on 12/17/24. The following were not posted as required: * The name of administrator or designee in charge posted by shift; * The LGBTQIA2S+ nondiscrimination notice; and * The Ombudsman notification poster was not posted in the separate memory care units 1 and 2. The need to ensure required postings were in a routinely accessible and conspicuous location to residents and visitors was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 4 (RCC) and Staff 6 (Director of Facilities) on 12/20/24. They acknowledged the findings.

Ombudsman poster for memory cares are ordered.12/22/24. All Posters posted 1/3/24 LBGTQIAS+ Are posted in Assisted living and both memory cares. Administrator Designee sign also posted. Signs will be checked monthly to ensure compliance by RCC/ADMIN

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

Based on interview and record review, it was determined the facility failed to conduct an initial move-in evaluation for 1 of 1 sampled resident (# 4) and failed to ensure move-in evaluations addressed all required elements, for 2 of 2 sampled residents (#s 5 and 6) whose evaluations were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 08/2024 with diagnoses including dementia. Resident clinical records were reviewed, and no documented evidence of an initial move-in evaluation was found for Resident 4. During an interview on 12/18/24, Staff 1 (Administrator) reported an initial move-in evaluation had not been completed for Resident 4. On 12/19/24, the need to ensure the facility conducted an initial move-in evaluation prior to admission was discussed with Staff 1. She acknowledged the findings. 2. Resident 6 was admitted to the facility in 11/2024 with diagnoses including depression and essential hypertension. The move-in evaluation, completed on 11/27/24, failed to address the following required elements: *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; and *Recent losses. The need to ensure all required elements were addressed in the move-in evaluation was discussed with Staff 1 (Administrator), Staff 2 (Executive Director) Staff 3 (LPN) and Staff 4 (RCC) at 11:00 am on 12/20/24. They acknowledged the findings. 3. Resident 5 moved into the facility in 11/2024 with diagnoses including hemiplegia and hemiparesis following cerebral infarction, and cognitive communication deficit. The resident's move-in evaluation was reviewed. The following required elements were not addressed: *Mental health issues, including history of treatment and effective non-drug interventions; * History of dehydration or unexpected weight loss or gain; and * Communication, including the ability to understand and be understood. The need to ensure the move-in evaluation addressed all required elements was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (LPN), and Staff 4 (RCC) on 12/20/24. They acknowledged the findings.

Resident #4 , # 5 and #6 will have an evaluation completed that addresses all required elements to ensure nothing was missed upon move in. Audit will be completed on all residents to ensure each resident has a move-in evaluation completed. Nurse Consultant will provide an in-service with the interdisciplinary team (IDT) on when to complete a resident evaluation. The HWD or designee will audit new move in (initial) evaluations for timeliness and all required elements. Audit details to be reported at Quarterly QA meeting.

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

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and preferences, provided clear direction regarding the delivery of services, and/or were implemented 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 1 moved into the facility in 01/2019 and had diagnoses including Alzheimer's Disease and chronic pain. Observations of the resident, interviews with staff, review of interim service plans, progress notes from 10/10/24 through 12/16/24, and service plan, dated 11/20/24, showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas: * Ability to communicate effectively; * Symptoms of anxiety and agitation for staff to monitor; * Two-person assist for bed mobility, toileting, dressing, showers, and transfers; * Non-ambulatory; * Wheelchair for mobility; * Grooming and Hygiene; * Meal assistance; * Pressure reducing cushion in wheelchair; * Pain in legs, including non-drug interventions with direction for staff; and * Weight loss history and interventions. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), and Staff 3 (LPN) on 12/19/24. The staff acknowledged the findings. 2. Resident 3 was admitted to the facility in 08/2022 with diagnoses including chronic pain and Type 2 diabetes. The resident's 10/17/24 service plan and temporary service plans dated 09/17/24 to 12/17/24 were reviewed, interviews with staff and the resident were conducted, and observations were made. The resident's service plan was not reflective of needs and preferences, did not provide clear direction to staff, and/or was not implemented in the following areas: *Anxiety presentation; *Inappropriate behavior; *Hallucinations/delusions; *Resistance to care; *Level of assistance required for mobility/ambulation, transferring, bathing, grooming, dressing and toileting; *Ability to use call pendant; *Emergency evacuation; *Pain including nonpharmacological interventions; and *History of weight loss. The need to ensure service plans were reflective, provided clear direction to staff, and were implemented was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (LPN) and Staff 4 (RCC) at 11:00 am on 12/20/24. They acknowledged the findings. 3. Resident 6 was admitted to the facility in 11/2024 with diagnoses including depression and essential hypertension. The resident's 11/27/24 service plan and temporary service plans dated 11/27/24 to 12/17/24 were reviewed, interviews with staff and the resident were conducted, and observations were made. The resident's service plan was not reflective of needs and preferences, did not provide clear direction to staff, and/or was not implemented in the following areas: *Vision loss and assistive devices; *Anxiety including symptom presentation and nonpharmacological interventions; and *Assistance required with dressing and emergency evacuation. The need to ensure service plans were reflective, provided clear direction to staff, and were implemented was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (LPN) and Staff 4 (RCC) at 11:00 am on 12/20/24. They acknowledged the findings. 4. Resident 5 moved into the facility in 11/2024 with diagnoses including hemiplegia and hemiparesis following cerebral infarction, and cognitive communication deficit. The resident’s service plan dated 11/14/24 was reviewed, observations were made, and interviews were conducted. The resident's service plan was not reflective of the resident’s needs and preferences and did not provide clear direction to staff in the following areas: * Level of transfer assistance; * Level of ambulation/locomotion assistance; * Compression socks; and * Resident preference for leaving apartment door open. The need to ensure service plans were reflective of residents' current needs and provided clear direction to staff for the provision of care was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (LPN), and Staff 4 (RCC) on 12/20/24. They acknowledged the findings. 5. Resident 2 was admitted to the facility in 07/2022, with diagnoses including dementia, depression, and hypertension. Review of Resident 2's most recent service plan, dated 11/18/24, interviews with staff, and observations of the resident revealed the service plan was not reflective of current status and care needs, or did not provide clear direction for staff in the following areas: * Dietary strategies and weight loss concerns; * Person-centered activity plan; and * Risk for skin breakdown. On 12/19/24 at 2:15 pm, the need to ensure service plans were reflective of current status and care needs, and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (LPN), and Staff 4 (RCC). They acknowledged the findings. 6. Resident 4 was admitted to the facility in 08/2024 with diagnosis including dementia. Resident 4's service plan, progress notes, incidents reports, and staff interviews identified the service plan was not reflective of the resident's preferences, current status, or lacked direction to staff in the following areas: * Dressing; * Ability to use a key; and * Resident unit door open or closed preference. On 12/19/24, the need to ensure service plans were reflective of resident needs and preferences was discussed with Staff 1 (Administrator). She acknowledged the findings.

Resident #1, #2, #3, #4, #5, #6 have been reviewed by the IDT to ensure their service plans reflect the resident’s current care needs and provide clear direction regarding delivery of services for all areas of care. Review of all resident service plans will be conducted to ensure the service plans are reflective of each resident’s care needs and provide clear direction to staff for the provision of care. Nurse Consultant or designee will provide education/in-service to the IDT on person centered service plans. HWD or Designee will review that the service plans are being updated quarterly and when there is a change in condition. Audit details to be reported at Quarterly QA meeting.

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

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the residents choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 2 of 4 sampled residents (#s 2 and 4) whose service plans were reviewed. Findings include, but are not limited to: Resident 2 and 4's most recent service plans lacked documentation a Service Planning Team reviewed and participated in the development of the service plans. On 12/19/24 at 2:15 pm, the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (LPN), and Staff 4 (RCC). They acknowledged the findings.

Resident #2 and #4 had another service plan meeting with resident/family invited and documentation was completed showing who participated in the service plan meeting. Beginning 1/13/25 the service planning team will complete the new form for each care conference held that includes who attended. The facility implemented a new service plan review form with each care conference effective 1/13/25. The HWD or Designee will audit for compliance 1x/week for 1 month and then 1x monthly thereafter. Audit details to be reported at Quarterly QA meeting

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

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who experienced short-term changes of condition had resident-specific actions or interventions determined and documented, and residents' changes of condition were monitored consistent with evaluated needs with progress noted at least weekly to resolution for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5 and 6) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 08/2022 with diagnoses including chronic pain and Type 2 diabetes. The resident's service plan available to staff, dated 10/17/24, temporary service plans dated 09/17/24 to 12/17/24, 12/01/24 to 12/17/24 MARs and progress notes dated 09/17/24 to 12/17/24 were reviewed, observations were made, and interviews with staff and the resident were conducted. The following short-term changes of condition, documented in the progress notes, lacked actions or interventions communicated to staff on all shifts and/or were not monitored at least weekly to resolution: * 09/23/24 – Unwitnessed fall; * 09/24/24 – Right foot diabetic ulcer; * 09/25/24 – New medication; * 10/08/24 – New skin breakdown, coccyx; * 10/19/24 – Unwitnessed fall; * 11/01/24 – Unwitnessed fall; * 11/01/24 – New symptom, gout; * 11/07/24 – Difficulty swallowing pills; * 11/08/24 – Unwitnessed fall; * 11/13/24 – Severe shoulder pain; * 11/15/24 – Unwitnessed fall; and * 12/08/24 – Unwitnessed fall. The need to ensure changes of condition had actions or interventions determined, implemented, communicated to staff on all shifts, and were monitored at least weekly to resolution was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (LPN) and Staff 4 (RCC) at 11:00 am on 12/17/24. They acknowledged the findings. 2. Resident 6 was admitted to the facility in 11/2027 with diagnoses including depression and essential hypertension. The resident's service plan available to staff, dated 11/27/24, temporary service plans dated 11/27/24 to 12/17/24, 12/01/24 to 12/17/24 MARs and progress notes dated 11/27/24 to 12/17/24 were reviewed, observations were made, and interviews with staff and the resident were conducted. The following short-term changes of condition lacked actions or interventions communicated to staff on all shifts and/or were not monitored at least weekly to resolution: * 11/27/24 – New move-in; * 12/05/24 – Unwitnessed fall with injury; and * 12/09/24 – Return from hospital. The need to ensure changes of condition had actions or interventions developed, implemented, communicated to staff on all shifts, and were monitored at least weekly to resolution was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (LPN) and Staff 4 (RCC) at 11:00 am on 12/20/24. They acknowledged the findings. 3. Resident 1 was admitted to the facility in 01/2019 with diagnoses including Alzheimer’s disease and chronic pain. The resident's 11/20/24 service plan and progress notes, interim service plans dated 10/10/24 through 12/17/24 were reviewed. The following short-term changes of condition lacked monitoring of progress noted weekly through resolution: * 10/10/24 – Diarrhea; * 11/07/24 – Elevated temperature; and * 11/19/24 – Admission to hospice. The need to ensure changes of condition had progress monitored at least weekly through resolution was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), and Staff 3 (LPN) on 12/19/24. They acknowledged the findings. 4. Resident 2 was admitted to the facility in 07/2022 with diagnoses including dementia, depression, and hypertension. Review of Resident 2's progress notes, dated 09/17/24 through 12/17/24, indicated the resident experienced the following changes of condition: * 09/22/24: A progress note revealed the discovery of “scratches on [his/her] left shoulder near [his/her] collar bone” while being assisted in shower; and * 10/31/24: A progress note revealed “[Resident 2] has a small skin tear on [his/her] left wrist that seems to be from [his/her] watch”. There was no documented evidence these skin conditions were monitored, at least weekly, to resolution. On 12/19/24 at 2:15 pm, the need to ensure short term changes of condition were monitored with progress noted, at least weekly, to resolution was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (LPN), and Staff 4 (RCC). They acknowledged the findings. 5. Resident 5 moved into the facility in 11/2024 with diagnoses including hemiplegia and hemiparesis following cerebral infarction, and cognitive communication deficit. The resident’s service plan, interim service plans, progress notes, and off-site healthcare provider notes were reviewed, and interviews with staff were conducted. The following was identified: A fax to the resident’s physician dated 12/06/24 stated resident’s “right great toe is red, inflamed and warm. [S/he] appears to have cellulitis starting.” An urgent care visit summary dated 12/07/24 documented diagnoses of cellulitis of left lower limb and localized edema. During an interview at 1:15 pm on 12/18/24, Staff 3 (LPN) acknowledged there was no documentation the above change of condition was monitored. The need to ensure short-term changes of condition were monitored weekly with progress noted was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (LPN), and Staff 4 (RCC) on 12/20/24. They acknowledged the findings. 6. Resident 4 was admitted to the facility in 08/2024 with diagnosis including dementia. Resident 4's clinical record was reviewed for changes of condition and monitoring from 09/18/24 through 12/18/24 and revealed the following: * 11/10/24: Resident to resident altercation; * 11/22/24: Became unresponsive during a meal, slump in chair, hit their head on the table, and began drooling; * 11/26/24: Found on the floor and was sent to the hospital; * 11/28/24: Found on the floor in front of their couch; * 11/29/24: Open skin area to the second digit of his/her right foot; and * 12/12/24: Found on the floor of the bathroom. There was no documented evidence the facility monitored the short-term changes of condition weekly through resolution. On 12/19/24, the need to monitor resident changes of condition weekly to resolution was reviewed with Staff 1 (Administrator). She acknowledged the findings.

Resident #1, #2, #3, #4, #5, #6, short term condition changes will be re-capped by the LN to ensure issues have been resolved and no further action/interventions are needed. LN to review short-term changes in condition for all other residents over the past 30-days (month of December) to ensure any issues/concerns have been resolved and/or need further action/interventions. THOUGHTS ON THIS ONE? Change in resident’s condition will be monitored and identified through the 24-hour chart review and follow-up process. The facility implemented a new 24-hour/alert charting policy and procedure/system. Changes in conditions will also be discussed at morning clinical meetings. Licensed nursing staff will be in-serviced on assessing and documenting changes in condition on a weekly basis until resolution. Med-techs and caregivers will be in-serviced on the new 24-hour and alert charting policy and procedure and reporting process for changes in resident conditions. Monthly audits will be completed by the Health and Wellness Director (HWD) or Designee to ensure that monitoring of changes in condition has been assessed timely and documented on weekly until resolution. Audit details to be reported at Quarterly QA meeting. HWD to ensure compliance

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

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed which documented findings, resident status, and interventions made as a result of the assessment for 1 of 2 sampled resident (# 1) who experienced a significant change of condition. Findings include, but are not limited to: Resident 1 was admitted to the facility in 01/2019 with diagnoses including Alzheimer’s disease and chronic pain. During the acuity interview on 12/17/24, staff reported the resident needed two-person assist with transfers and was “heavy care” for ADLs. Observations of Resident 1 during survey revealed s/he remained in bed for most of the time, getting up only for two meals. Two staff provided assistance with bed mobility, incontinence cares, dressing and transfer to the wheelchair. Total one person assist was provided for grooming and hygiene tasks. Interviews with staff and review of the resident's 11/20/24 service plan, temporary service plans, and 10/10/24 through 12/17/24 progress notes, were completed. The service plan, with an activation date of 07/09/24, last updated on 11/20/24, indicated the resident required minimum assist with transfers, was ambulatory with a walker up to 150 feet and set up, supervision and cueing for grooming and hygiene as needed. Staff 13 (CG) and Staff 19 (CG) reported that Resident 1 was not able to walk any longer, needed total one to two person assist in all ADL cares, and at times feeding assist was provided. Staff reported that in 08/2024 the resident was able to ambulate with a walker with one person assist. During an interview with Staff 5 (RN) on 12/18/24, she reported an assessment had been completed for Resident 1. She provided documentation of an RN change of condition note dated 11/21/24 indicating hospice services had been started on 11/19/24, without any documentation related to the resident’s significant decline in ADLs and mobility. The need to ensure an RN assessment was completed for significant changes of condition which included resident status and interventions made as a result of the assessment was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), and Staff 3 (LPN) on 12/19/24. No further documentation was provided.

The RN completed a significant change in condition assessment for resident #1 and updated interventions to reflect her current ADL’s and medical condition. The HWD or designee will audit all resident charts who are on hospice to ensure there is an RN change in condition assessment completed with interventions that have detailed instructions on resident’s current ADL and medical condition. Facility hired a new RN and will take "Role of the RN in CBC setting" on February 18th- 20th, 2025. RN/LPN will enroll in the Nurse Learn program for Licensed Nurses and take the modules for Changes in Resident Condition. Significant changes in resident condition will be monitored and identified through the 24-hour chart review and follow-up process. The facility implemented a new 24-hour/alert charting policy and procedure/system. Changes in conditions will also be discussed at morning clinical meetings for appropriate follow-up by RN. Monthly audits will be completed by the HWD or designee to ensure that significant changes in condition have a RN assessment completed timely with detailed instructions/interventions for staff to follow. Results of audit to be reported to the QA meeting quarterly.

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 resident-specific parameters and instructions for PRN medications were included on the MAR and/or the MAR included all required components, including medication specific instructions, for 2 of 6 sampled residents (#s 2 and 3) whose MARs were reviewed. Findings include, but are not limited to: 1.Resident 3 was admitted to the facility in 08/2022 with diagnoses including chronic pain and Type 2 diabetes. The resident's 12/01/24 to 12/17/24 MAR was reviewed and revealed the following: a. PRN medications for pain lacked resident-specific parameters for administration: *Hydrocodone-acetaminophen 5-325 mg; and *Acetaminophen 325 mg. b. There was no documented evidence of resident-specific instructions for administration of PRN naloxone 4 mg/0.1ml (for opioid overdose). c. There was no documentation of where the Buprenorphine transdermal patch (for pain) was applied. d. Medication administration instructions for levothyroxine 150 mcg (for hypothyroidism) including that the medication should be taken 30 minutes before food, coffee, or other medications and on an empty stomach, were not included on the MAR. The need to ensure medications contained resident-specific parameters and instructions for administration was discussed with Staff 1 (Administrator), Staff 2 (Executive Director) Staff 3 (LPN) and Staff 4 (RCC) at 11:00 am on 12/20/24. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 07/2022, with diagnoses including dementia, depression, and hypertension. Review of Resident 2’s MAR, dated 12/01/24 through 12/17/24, identified the following: The MAR lacked resident-specific parameters for use of the following PRN pain medications, and PRN bowel medications: * Four PRN medications for constipation were listed on the MAR: bisacodyl 10 mg supp, Senna 8.6 mg tab, Milk of Magnesia 400 mg/5ml, Glycerin 2 gm supp. There were no instructions for the sequential order of administration of these medications; and * Three PRN medications for pain were listed on the MAR: acetaminophen 325 mg tab (for pain or fever), acetaminophen 650 mg supp (for pain or fever) and morphine sulfate 100 mg/5 ml sol (for pain or shortness of breath). There were no instructions for the sequential order of administration of these medications. The need to ensure MARs were accurate, and included clear parameters and direction to staff for medication administration was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (LPN), and Staff 4 (RCC). They acknowledged the findings.

Resident #3 and #2 EMARs were reviewed and updated to include resident specific instructions/parameters for prn medications. Licensed nurse will review all resident MARs for appropriate instructions/parameters for all PRN medications. Licensed Nurse to include resident specific instructions/parameters for prn medications during process of confirming orders. Pharmacy Consultant or designee will audit for resident specific instructions/parameters during their quarterly audit. HWD will follow-up to ensure recommendations have been completed. Nurse Consultant will do random audits during routine visits to ensure compliance.

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.

Based on interview, and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications were evaluated at least quarterly to assure the residents' ability to safely self-administer medications and had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications for 1 of 1 sampled resident (# 7) who was reviewed for self-administration. Findings include, but are not limited to: Resident 7 was admitted to the facility in 12/2023 with diagnoses including arthritis and diabetes. During the acuity interview on 07/22/24, Resident 7 was identified as self-administering his/her medications. Review of Resident 7's medical records revealed there was no documented quarterly evaluation of Resident 7's ability to safely self-administer medications after 07/10/24, and no physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications. In an interview on 12/18/24, Staff 1 (Administrator) acknowledged no physician or other legally recognized practitioner's written order was available, and the most recent quarterly evaluation was not completed timely. The need to ensure residents who chose to self-administer their medications were evaluated at least quarterly to assure the residents' ability to safely self-administer medications and had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications was reviewed with Staff 1, Staff 2 (Executive Director), and Staff 3 (LPN) on 12/19/24. They acknowledged the findings. No further information was provided.

Licensed Nurse to complete a self-med assessment for resident #7 and obtain a physician order if appropriate. LN will assess a resident upon move-in and if assessed to be able to safely administer their medications will obtain a physician’s order and will complete a self-med assessment quarterly thereafter or when there is a change in condition or ability to self-administer own medications. HWD or designee will review all residents who are administering their own medications to ensure there is a self-med assessment completed by a LN at least quarterly and/or with a change in condition and that there is a physician’s order in place to self-administer. HWD or designee to monitor for compliance monthly x2 months and then quarterly thereafter.

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

Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed by an RN, PT or OT, less restrictive alternatives prior to use were documented, instruction was provided to caregivers on the correct use of and precautions for the device, and use of the device was documented in the resident's service plan for 2 of 2 sampled resident (#s 1 and 3) who had side rails on his/her bed. Findings include, but are not limited to: 1.During an interview at 9:54 am on 12/19/24, Resident 3 stated s/he had bilateral side rails on his/her bed. Interviews with care staff confirmed the resident did currently have side rails on his/her bed. There was no documented evidence the following required elements were completed: * Thorough assessment by an RN, PT or OT; * Documentation of less restrictive alternatives evaluated prior to use of the device; * Instruction provided to staff on the correct use and precautions related to the device; and * Documentation of side rails in the resident's service plan. The need to ensure the use of a supportive device with potentially restraining qualities was assessed by an RN, PT or OT, included documentation of all required elements and was included in the resident's service plan was discussed with Staff 1 (Administrator), Staff 2 (Executive Director) Staff 3 (LPN) and Staff 4 (RCC) at 11:00 am on 12/20/24. They acknowledged the findings, and no additional documentation was provided. 2. Resident 1 was identified during acuity interview as having side rails on his/her bed and was observed on 12/17/24 to have half side rails in the up position on both sides of the bed. Review of the resident's clinical record revealed the following: * No documented evidence of an assessment completed by an RN, Physical Therapist or Occupational therapist for the use of the side rail or seatbelt; and * No documented evidence that other less restrictive alternatives had been attempted prior to use. The need to complete an assessment and the required components for the use of devices with restraining qualities was discussed on 12/17/24 with Staff 1 (Administrator) and 12/19/24 with Staff 1, Staff 2 (Executive Director) and Staff 3 (LPN). They acknowledged the findings. The side rails were removed from the bed on 12/18/24.

Resident #1 siderails were removed from bed on 12/18/24. Resident #3 device with restraining quality had an assessment completed on and service plan was updated to reflect current device being used. RN to assess each resident who has a device with restraining qualities and document required elements on service plan. Residents with current devices will be re-assessed on a quarterly basis and/or with a change in condition. The HWD or designee to monitor for compliance monthly x2 months and then quarterly thereafter.

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 ensure their Acuity-Based Staffing Tool (ABST) accurately captured care time and care elements that staff were providing to residents. Findings include, but are not limited to: A review of the facility’s ABST revealed the care times and care elements documented for cares provided by staff were not accurate for Residents 1, 4, and 6. On 12/19/24 the need to ensure the ABST accurately captured care time and care elements was discussed with Staff 1 (Administrator). She acknowledged the findings.

Resident #1, #4, #6 were updated on the ABST to reflect current care time and care elements that staff provide to these residents. The Administrator will review all other residents on the ABST to ensure the Acuity Based Staffing Tool accurately captures care time and elements. Administrator will be inserviced On completing ABST This will be done upon move in, quarterly, with significant change of condition or as needed

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 ABST (Acuity-Based Staffing Tool) was updated at least quarterly and/or with significant changes of condition to determine appropriate staffing levels to address activities of daily living and other tasks related to care. Findings include, but are not limited to: The facility had a census of 78 residents at the time of survey. Review of the facility’s ABST Tool showed 40 of 78 residents’ ABST information was not updated quarterly and/or with a signficant change of condition to reflect the residents’ current care needs and status. On 12/19/24, the need to ensure the ABST tool was updated no less than quarterly and with significant changes of condition to determine appropriate staffing levels to address activities of daily living and other tasks related to care was discussed with Staff 1 (Administrator). She acknowledged the findings.

The administrator will ensure that ABST is updated upon move in, Quarterly and with significant changes of condition Administrator or designee will review ABST for Accuracy for all residents Administrator will be inservied on completing the ABST

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 4 of 4 newly hired staff (#s 18, 21, 24, and 26) completed abdominal thrust training within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 12/20/24. There was no documented evidence Staff 18 (CG), Staff 21 (CG), Staff 24 (MT), and Staff 26 (MT) hired on 09/19/24, 10/18/24, 08/21/24, and 10/31/24 respectively, completed abdominal thrust training within 30 days of hire. On 12/20/24, the need for staff to complete all required training within the specified time frames was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), and Staff 4 (RCC). They acknowledged the findings.

Abdominal Thrust training, has been completed for 4 staff that were missing it by licensed Nurse All New employees will complete state required Training with in their first 30 days of hire. A licensed nurse will complete abdominal thrust training within 30 days of starting floor training. Annual training to be completed yearly, New hires will have Abdominal thrust training within 30 days of hire. Wellness director/ RCC/Admin to ensure this is completed.

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

Based on interview and record review, it was determined the facility failed to conduct fire drills every other month in accordance with the Oregon Fire Code. Findings include, but are not limited to: Review of fire drill and fire and life safety records for June 2024 through December 2024 identified the following deficiencies: * Fire drills were not being conducted and recorded every other month; * The facility was not relocating residents from the simulated fire area; therefore, there was no documentation of: - The escape route used; - Problems encountered, comments relating to residents who resisted or failed to participate in the drills; - Evacuation time-period needed; and - Number of occupants evacuated. On 12/19/24, multiple staff were interviewed. The staff were unable to state the designated point of safety as determined by the Fire Authority having jurisdiction. On 12/20/24, the need to ensure fire drills were conducted in accordance with the Oregon Fire Code was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), and Staff 6 (Director of Facilities). They acknowledged the findings.

Conduct all missing fire drills for the review by 2/18/25 ensuring proper documentation. Date time, simulated fire origin, escape routes, evacuation time, and staff/resident participation. Ensure residents are relocated to designated points of safety during drills. Provided refresher training to staff on fire evacuation procedures and designated points of safety. Fire drills and staff trainings have been set on an alternating schedule each month for the remainder of the year and ongoing. Fire drill documentation form has been updated to include all required elements. ED, Admin or designee to audit documentation monthly and correct as needed. ED, Admin, Maintenance Director or designee to monitor for compliance

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

Based on interview and record review, it was determined the facility failed to ensure residents were instructed in fire and life safety procedures within 24 hours of admission and re-educated at least annually. Findings include, but are not limited to: Fire and life safety records were reviewed on 12/19/24, and the following was identified: There was no documented evidence residents were educated in general fire and life safety procedures, evacuation methods, responsibilities, and designated meeting places inside or outside the building in the event of an actual fire within 24 hours of admission and re-educated at least annually. On 12/20/24, the need to ensure fire and life safety instruction was provided to each resident within 24 hours of admission and at least annually as required by the Oregon Fire Code was discussed with Staff 1 (Administrator). She acknowledged the findings.

1)By 2/18/25 will identify all residents missing fire life and safety covering general safety procedures, evacuation methods, responsibilities and meeting points. Document all training records with participation records. Provide initial training for new residents within 24hrs of admission.Update the admission process to include mandatory fire life and safety training. Annual fire life and safety was completed in April of 2024.Training scheduled for re-education for all residents during March of 2025. New move in's will be educated within 24hours of move in on fire life and safety plan. We will annually audit records to ensure re-education for all residents. Maintenance director, Admin or designee to ensure compliance.

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

Based on observation and interview, it was determined the facility failed to ensure the environment was clean and maintained in good repair. Findings include, but are not limited to: The facility was toured on 12/17/24 and the following was observed: * The carpet in the hallway of the east side of the building on the 2nd floor had multiple dark stains of varying sizes throughout; * Several of the chairs in the dining room and common areas had gouges on the legs and were worn and stained in the memory care units 1 and 2; and * The toilets in the community bathrooms on the first and second floor near the elevator and the toilets in the community bathrooms in the memory care units 1 and 2 had missing or stained caulking around the base of the toilets. On 12/20/24, the areas in need of cleaning and repair were discussed with Staff 1 (Administrator), Staff 2 (Executive Director), and Staff 6 (Director of Facilities). They acknowledged the findings.

On 12/19/24 a contracted carpet cleaning company came during the noc hours to clean carpets noted in state findings. Caulking around toilets were completed in community restrooms on 1/09/25. Maintenance to train additional staff to perform carpet cleaning. Carpet cleaning will be completed bi weekly on Fridays and as needed. Common area and dining room chairs will be repaired and in good condition by 2/18/25. Monthly rounding with maintenance, ED , Admin or designee will be completed to ensure common area furniture and equipment is in good conditon.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 152, C 362, C 363, C 372, C 420, C 422, and C 613.

Refer to C152, C362, C363,C372, C420,C422 and C613

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) 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 when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 18, 21, 24, and 26) demonstrated competency in all job duties within 30 days of hire, and 3 of 4 long-term staff (#s 16, 17, and 21) completed the required number of hours of annual in-service training. Findings include, but are not limited to: Staff training records were reviewed on 12/19/24 and 12/20/24. a. There was no documented evidence Staff 18 (CG), Staff 21 (CG), Staff 24 (MT), and Staff 26 (MT) hired on 09/19/24, 10/18/24, 08/21/24, and 10/31/24 respectively, demonstrated competency in their job duties within 30 days of hire in the following areas: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Identification, documentation, and reporting changes of condition; * Conditions which require assessment, treatment, observation, and reporting; and * General food safety, serving, and sanitation. b. There was no documented evidence Staff 16 (CG), Staff 17 (CG), and Staff 25 (MT) hired on 05/10/22, 07/26/22, and 06/24/21, respectively completed the required minimum of 16 hours of annual in-service training, with 10 hours related to the provision of care in Community Based Care and six hours related to dementia care. On 12/20/24, the need to ensure all staff training was completed in the required time frames was discussed with Staff 1 (Administrator), Staff 2 (Executive Director) and Staff 4 (RCC). They acknowledged the findings.

The Four identified staff members completed their intial Competencies, The other three idenified staff members completed the annual training. Resident care coordinator will ensure documentation of demonstrated competency will be completed within 30 days of hire. RCC will ensure documentation of 16 hours annual inservice training with 10 hours of related to the provision of care in CBC and 6 hours related to dementia care is completed annually. Admin and RCC will be responsible for Compliance

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 252, C 260, C 262, C 270, C 280, C 310, C 325 and C 340.

Refer to C252, C260,C270, C280, C310, C325 AND C340

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities.

Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 3 of 3 sampled MCC residents (#s 1, 2, and 4) whose activity plans were reviewed. Findings include, but are not limited to: Residents 1 ,2, and 4's records were reviewed during the survey. There was no documented evidence an activity evaluation had been completed and the service plans individualized, to reflect one or more of the following required components: * Residents' current preferences; * Abilities and skills; * Emotional/social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Identification of activities for behavioral interventions. There was no specific activity plan which detailed what, when, how and how often staff should offer and assist each resident with individualized activities. On 12/19/24 at 2:15 pm, the need to evaluate and develop individualized activity plans including all required components for each memory care resident was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (LPN), and Staff 4 (RCC). They acknowledged the findings.

Resident care coordinator will ensure activity plan is completed upon move in, and quarterly and if there is a change. Residents #1, #2 and# 4 have had activity plan completed. All Memory care residents charts will be audited to ensure there is a current activities plan in place. Activity plan will be kept in resident chart and a copy with their service plan available to staff. Rcc or designee to audit charts, and ensure completion of all memory care residents activities plan

Based on interview and record review, conducted during a site visit on 05/09/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#1). Findings include, but are not limited to: A review of Resident 1's February 2024 MAR and progress notes, investigation form dated 02/26/24, and picture of the bubble pack, indicated the following: · MAR shows Levetiracetam oral tablet 500 MG; Take 1 tablet by mouth twice daily, in the morning and at bedtime, · MAR was signed off as given on 02/21/24 at 10:00 am and 10:00 pm, · Picture of the bubble pack shows the medication was not popped, · Investigation form indicated  "med tech clicked off the medication and did not administer the medication, it was still sitting in the bubble pack". In an interview, Staff 1 (Administrator) and Staff 2 (RN) stated the incident did occur. The findings were reviewed with and acknowledged by Staff 1 and Staff 2 on 05/09/24. It was confirmed the facility failed to carry out medication and treatment orders as prescribed. Verbal plan of correction: Self-reported med error. Additional training on med cart provided to staff. MT meetings every 2 weeks with the ED and RN.

The findings of the on-site investigation, conducted 02/27/24, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT:            Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse

The findings of the on-site investigation, conducted 02/27/24, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT:            Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse

The findings of the on-site investigation, conducted 07/11/23 through 07/11/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT:             Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse

The findings of the on-site investigation, conducted (date) through (date), are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT:             Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse

The findings of the on-site investigation, conducted 07/11/23 through 07/11/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT:            Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse

The findings of the on-site investigation, conducted 07/11/23 through 07/11/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT:            Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse

The findings of the on-site investigation, conducted 07/11/23 through 07/11/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT:            Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse

The findings of the on-site investigation, conducted 7/11/23 through 7/11/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT:            Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse

The findings of the on-site investigation, conducted 7/11/23 through 7/11/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT:            Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse

Based on interview and record review, conducted during a site visit on 07/11/23, it was confirmed the facility failed to ensure service plans were updated quarterly for 2 of 2 sampled residents (#s 4 and 5), whose service plans were reviewed. Findings include, but are not limited to: Compliance Specialist reviewed Resident 4's most current service plan dated 01/03/23, and Resident 5's service plans dated 10/06/22 and 06/21/23. There was no documented evidence Resident 4's service plan had been updated since 01/03/23, and no documented evidence Resident 5's service plan had been updated between 10/06/22 and 06/21/23. During an interview, Staff 1 confirmed resident service plans had not been completed on time, however s/he had just started working at the facility on 07/01/23 and had 20 care conferences scheduled for the upcoming week. The findings were reviewed with and acknowledged by Staff 1 and Staff 2 (Assistant Executive Director) on 07/11/23. It was confirmed that the facility failed to ensure service plans were updated quarterly. Verbal plan of correction: New ED started on 07/01/23 and has care conferences already scheduled this week to stay current on care plans. They currently do not have any that are past due. They are using the program Yardi, which alerts them when they have upcoming service plans due. Based on interview and record review, conducted during a site visit on 07/11/23, it was confirmed the facility failed to ensure service plans were updated quarterly for 1 of 1 sampled resident (#1), whose service plans were reviewed. Findings include, but are not limited to: Compliance Specialist reviewed Resident 1's service plans dated 12/29/22 and 05/16/23. There was no indication the facility had completed any other service plans between the two dates. During an interview, Staff 1 (Executive Director) confirmed the facility had been behind on resident service plans, and stated s/he had just started working at the facility on 07/01/23. Staff 1 further stated s/he had 20 care conferences scheduled for the upcoming week. A review of the facility's computer system indicated the facility was currently caught up. The findings were reviewed with and acknowledged by Staff 1 and Staff 2 (Assistant Executive Director) on 07/11/23. It was confirmed the facility failed to ensure service plans were updated quarterly. Verbal plan of correction: New ED started on 07/01/23 and has care conferences already scheduled this week to stay current on care plans. They are using the program Yardi, which alerts them when they have upcoming service plans due.

Based on interview and record review, conducted during a site visit on 07/11/23, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 3 of 3 sampled residents (#'s 3, 4, and 5). Findings include, but not limited to: Resident 3's signed physicians orders, April 2023 Medication Administration Record (MAR), and facility self-reported fax dated 05/05/23, indicated that on 04/30/23, Resident 3 missed his/her 8:00 pm dose of Diltiazem 120 mg, Flovent 110/mcg/act, Gabapentin 300 mg, Isosorsbide Monomitrate 60 mg, Ipratropium-Albuterol, and Metoprolol 50 mg. Resident 4's signed physicians orders, April 2023 MAR, and facility self-reported fax dated 05/05/23, indicated that on 04/30/23, Resident 4 missed his/her 8:00 pm dose of Atorvastatin 40 mg, Eliquis 5 mg, Lisinopril 20 mg, and Trazadone 50 mg. Resident 5's signed physicians orders, April 2023 MAR, and facility self-reported fax dated 05/05/23, indicated that on 04/30/23, Resident 5 missed his/her 8:00 pm dose of carbidopa-levodopa 25-100, cephalexin 500 mg, Docusate 100 mg, Donepezil 5mg, simvastatin 20 mg, and Tamsulosin 0.4 mg. During an interview, 7/11/23, Staff 1 (Executive Director) stated s/he was not working at the facility during the time of the medication errors, however, the incidents did occur. A staff member walked off their shift and did not pass their scheduled 5:00 pm or 8:00 pm medications. S/he stated during their investigations they did not find any residents who requested or missed any PRN medications. Staff 1 confirmed, all residents who missed their scheduled dose of medication during that time frame had been reported to APS. The findings were reviewed with and acknowledged by Staff 1 and Staff 2 (Assistant Executive Director) on 07/11/23. It was confirmed the facility failed to carry out medication and treatment orders as prescribed. Verbal plan of correction: Facility notified APS of all residents who missed their meds on 4/30/23 during swing shift. Starting in May 2023 the RN did education with staff regarding med passes, orders, PRN follow up, and who to contact when issues arise. They are monitoring the Yardi system daily (clinicians and administration). Continuous med training is ongoing and they will be switching to utilizing a med cart instead of their previous system for passing meds. The previous ED and LPN no longer work at the facility and the new ED Shayna started 7/1/23.

Based on observation and interview, conducted during a site visit on 07/11/23, it was confirmed the facility failed to provide a call system that connects resident units to the care staff center or staff pagers for 1 of 1 sampled resident (#2). Findings include, but are not limited to: On 07/11/23, at 12:46 pm, Compliance Specialist (CS) observed Resident 2 push his/her call light pendant. After waiting 15 minutes outside of Resident 2's room, CS found Staff 5 (CG) and Staff 6 (CG) in the hallway and asked to see their pagers. Resident 2's call did not register on the pagers until Staff 5 scrolled through his/her pager to review previous calls. After reviewing the previous calls, Resident 2's page came through.   Staff 5 and 6 both stated sometimes the call lights didn't show up on the pagers at all, they were delayed, or would show up on one pager and not the other. They stated they only had three pagers and one was broken. Resident 2 stated, s/he recently had received a new pendant, and the call light was still not working. The findings were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 (Assistant Executive Director) on 07/11/23. It was confirmed the facility failed to provide a call system that connected resident units to the care staff center or staff pagers. Verbal plan of correction:  Administrator did an audit last week. Some areas are not getting the signal right away when pendants are pressed. They are going back to the old walkie talkies that they know worked and ordering new pagers rush order. They will also be monitoring the call lights at the receptionist area. Staff will be re-educated on Thursday 7/13/23 at an in-service and there will be frequent 2-hour checks on residents until the new pagers and walkies arrive. They expect this to be completed by the end of the week.

The findings of the on-site investigation, conducted on 07/11/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT:            Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse

Based on observation, interview and record review, it was determined the facility failed to maintain the kitchen in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. The facilities kitchen was observed in an extremely unsanitary condition and posed an immediate jeopardy situation that could threaten the health, safety, and/or welfare of residents. The kitchen was closed for deep cleaning and repairs on 050/2/23. Findings include, but are not limited to: Observation of the main campus kitchen on 05/02/23 at 10:00 am revealed the following areas. This kitchen was preparing the meals for this facility on the day of survey; a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following: * Pipes, walls, gauges, disposal, drain, walls and flooring behind/underneath the dish machine; * Spice shelves; * Juice dispenser; * Kitchen drains; * Electrical outlets and light switches; * Trash cans; * Pipes and flooring underneath the three compartment sink; * Interior and exterior of cabinets and drawers; * Ceiling fire sprinklers, smoke detectors and vents; * Walls throughout kitchen; * Vents on ice machine; * Plastic container that stores ice scoop; * Hand washing sink and faucet; * Cabinets under the steamtable; * Inside and outside of drawers storing utensils; * Interior and exterior of fryer; * Interior and exterior of microwave; * Stove/grill knobs, doors, interior, exterior; * Interior/exterior of ovens/steamer; * Handles of reach in coolers/freezers; * Wall behind hand wash sink and the sink; * Open shelving throughout kitchen; * Industrial mixer and slicer; * Table top mixer; * Bulk food bins; * Stainless steel drawers under mixer; * Large can opener; * Floors throughout the kitchen had black matter build-up, food debris and grease in corners, under equipment and around perimeter edges; * Large can goods storage rack; * Rack shelving in dry good storage; * Rack shelving storing equipment and dishes; * Under and behind shelving in dry good storage; * Door thresholds; * Walls throughout kitchen; * Open shelving throughout kitchen; * Walk-in cooler racks with dried food and black mold like substance; * Walk in freezer and cooler floors; * Walk in cooler shelving and doors/windows; * Fan near prep area with dust; * Beverage area in dining room walls and beverage dispensers. * Ceiling vents and fire sprinkler heads; * Industrial toaster; * Interiors and exteriors of stainless steel drawers; and * Interior of reach in refrigerator in dining room. b. The following areas were in need of repair: * Multiple areas of untreated wood throughout kitchen areas including in coolers and freezers; * Cabinets and cupboards with chipped/ pealing wood; * Cabinets under tray line service with noted rotting and decaying wood; * Pipe in store room with accumulation of black mold like substance; * Walk in freezer with large ice accumulation; * Multiple cracked or missing tiles throughout the flooring; * Under dish machine with hole in wall with access to the outside; * Hole in wall under steamer. * Standing water under steamer; * Crack in ceiling in dry storage; * Gap by sprinkler head in dry storage; * Rusted metal racks in freezer and walk in cooler; c. Cutting boards were heavily scored and/or stained. d. Piece of dirty frayed carpet in dry storage under a pole. e. Multiple cups of fruit and plates of deserts stored uncovered in the walk in cooler. f. Plastic cups observed with heavy staining. g. All trash cans in kitchen did not have lids for when not in use. i. Food service paper products stored in laundry space. j. Ware washing machine not reaching necessary temperature of 180 degrees F for sanitization. Staff did not have sanitizer strips available for testing concentration of sanitizer buckets. k. Multiple items were stored on the walk in freezer floor. Staff 4 (Kitchen Manager) toured areas with surveyor and acknowledged identified items in need of cleaning and/or repair. The South area kitchen was toured at 11:30 am and revealed the following areas. a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following: - Tile walls in steam table service area; - Interior and exterior of microwave in kitchen and in dining room; - Industrial mixer; - Walls throughout kitchen; - Floors throughout kitchen; - Floors in walk in cooler and freezer; - Floors and walls in dry storage; - Under storage racks in dry storage with build up of dirt and debris with visible rodent excrement found; - Reach in coolers and freezers; - Open stainless steel shelving; - Interior and exterior of drawers; - Interior and exterior of ovens; - Grill and stove, - Vents above stove; - Interior and exterior of dining room microwave, - Juice and cocoa machines; - Beverage service area in dining room; and - Interior and exterior of cabinets in dining room. b. The following areas were in need of repair: - Corners of walls with chips and nicks/damage to paint/wood; - Thresholds of doorways; - Multiple areas of untreated and porous wood; - Reach in freezer with ice build up and visual product damage to food; - Hood vents not serviced since 2012; - Multiple holes/gaps in storage rooms were possible pests could enter into kitchen; and - Black mold like substance in grout by dish machine. c. Blue utility cart dirty and damaged making areas uncleanable. d. Ware washing machine not reaching necessary temperature of 180 degrees F for sanitization. Staff did not have sanitizer strips available for testing concentration of sanitizer buckets. e. Staff was not observed to check temperatures of food items prior to beginning of tray service when satellite bulk food items from Churchill estates kitchen arrived. At approximately 12:00 pm on 05/02/23, the surveyor contacted the Community Based Care Supervisor and shared concerns about the unsanitary condition of the kitchen.  A decision was made to close the kitchen until the unsanitary and unsafe condition was rectified, and a long term plan was put in place. In an interview on 05/02/23 at 12:30 pm, Staff 1 (Campus Executive Director) and Staff 2 (Administrator) and were informed by the surveyor that the kitchen would be shut down for immediate cleaning. They were instructed to submit an immediate plan of correction to address the unsanitary and unsafe conditions. At that time the surveyor toured Staff 1 and 2 to the areas in the kitchen driving the immediate action. Staff 1 and 2 acknowledged the concerns. A plan to suspend kitchen operations until sanitation conditions improved was submitted. At 4:55 pm a plan to provide meals from outside food vendors to all residents while the sister facility kitchen was cleaned and able to operate under sanitary conditions. A pest control company was contracted to inspect areas for pests and treat as necessary. Cleaning vendors were contacted. The plan was reviewed and approved by the surveyor on site. On 05/05/23 at 4:00 pm, the surveyor reviewed the status of cleaning and approved use of Churchill retirement south kitchen for meal preparation for facility meal services. At that time the Immediate Jeopardy situation was abated and facility was able to resume dietary service for it's residents. The kitchen for the independent living and north AL residents continued to be closed for cleaning and repair. The south kitchen would be utilized as the primary kitchen for the campus.

A combination of facility staff and outsourced cleaning company will be utilized to ensure that all areas listed on p 4-5 are corrected up to standards as outlined in OAR 411- 054-0030. Cleaning checklists will be implemented and monitored by the kitchen supervisor to ensure standards are maintained. All kitchen staff will be trained on these checklists to ensure proper completion. All items on list will be repaired up to standards as outlined in OAR 411-054-0030 (1)(a). Cutting boards will be replaced and kitchen supervisor will monitor for any 'scoring/stains' and replace as necessary to ensure standards are maintained. Piece of carpet will be removed, area cleaned and maintained. All kitchen staff will be trained on proper storage of food in refridgerators in accordance with Oregon State food handling requirements in accordance with OAR 411-054-0030(1)(a). Trash can lids will be provided for when not in use. Dish machine temperature will be taken and recorded daily to ensure machine is operating appropriately. Sanitizer strips will be stored in an easy to access area of the kitchen to ensure staff test the concentration of sanitizer buckets every 2 hours to maintain a concentration of (50- 200ppm). All items on the walk in freezer floor will be removed and propery stored in accordance with OAR 411-054-0030(1) (a). Kitchen supervisor will monitor and maintain general cleanliness / accessability of walk in freezer.A combination of facility staff and outsourced cleaning company will be utilized to ensure that all areas listed on p 4-5 are corrected up to standards as outlined in OAR 411- 054-0030. Cleaning checklists will be implemented and monitored by the kitchen supervisor to ensure standards are maintained. All kitchen staff will be trained on these checklists to ensure proper completion.All items on list will be repaired up to standards as outlined in OAR 411-054-0030 (1)(a) Utility cart will be removed. New cart will be purchased and utlized as required for proper functioning of kitchen. Dish machine temperature will be taken and recorded daily to ensure machine is operating appropriately. Sanitizer strips will be stored in an easy to access area of the kitchen to ensure strips are used to check once in the morning to ensure the chemical amount is correct (50- 200ppm) and to change the bucket solution every two hours. Staff will ensure they check temperatures of food items prior to beginning of tray service when satellite bulk food items for Churchill estates kitchen arrive. Kitchen supervisor will ensure all staff have easy to access food temperature guidelines and thermometer with them at time of service.

Based on record review and interview, it was determined the facility failed to ensure 2 of 18 staff (#5 and 6) who prepared and served food had active food handlers certificates. Findings include, but are not limited to: On 5/2/23 employee records were requested and reviewed to ensure staff had active food handlers cards. There were three employees who's food cards could not be located. Staff 3 (Business Office Manager) indicated the HR representative may have better idea where they were. On 05/05/23, the surveyor asked for food cards for the missing employees. Active food cards could not be located and the surveyor was provided electronic copies of food cards dated 05/05/23 on 05/05/23. Staff 3 acknowledged Staff 5 and 6's active cards were not located at the time of survey.

Administrator will ensure all staff obtain and maintain their food handlers certificates in accordance to OAR 411-054-0070 (3-4) and certificates are stored in the employee files at all times.

Based on observation, record review and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 240.

See above for plan of correction for C240. Plan of Correction submitted 05/02/2023 approved 05/02/2023 at 4:55pm

The findings of the kitchen inspection, conducted 05/02/23 through 05/05/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. Situations were identified where there was a failure of the facility to comply with the Department's rules that were likely to cause residents serious harm. Immediate plans of correction were requested in the following area: OAR 411-054-0030 Resident Service Meals, Food Sanitation Rules. The facility put an immediate plan of correction in place during the survey and the situations were abated.

The findings of the revisit to the kitchen inspection of 5/5/23, conducted 8/8/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on interview and record review, it was confirmed that the facility failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. Findings include: In interviews on 12/14/22, Staff #1 stated that they are usually pretty good about reporting to APS. Staff should be documenting on the incident report when it is reported to APS. In review of the facility's policy and procedures for reporting to APS and an incident report dated 10/27/22 for Resident #2, there was no evidence to show that the information was actually reported to APS. Per policy, the administrator is responsible for notifying APS. No email verification was found. There is a note on the incident report that states "reporting incident to APS for further investigation"  however, there is no date or time reported that this was completed. APS did have a report, however, it did not come from the facility. The above information was shared with Staff #1 on 12/14/22, who was in agreement. Plan of correction: Re-training to staff regarding APS reporting requirements and what information needs to be provided. Training on incident report documentation.

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 12/14/2022.  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 11/01/2022.  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 09/21/2022.  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 09/21/2022.  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 09/21/2022.  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 9/21/2022.  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 09/21/2022.  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 interview and record review, it was determined the facility failed to conduct an investigation of an injury of unknown cause to rule out abuse and/or neglect and report the injury as suspected abuse to the local Seniors and People with Disabilities (SPD) office, for 1 of 1 sampled resident (#5). Findings include, but are not limited to: Resident 5 was admitted to the facility in 03/2019 with diagnoses including dementia. Review of incident reports, skin sheets, chart logs, and progress notes from 10/24/21 through 01/24/22 showed the following: * On 12/29/21, staff documented a large bruise was found on the resident's back right ribcage and the resident was unable to recall how s/he obtained the bruise. There was no further information about the incident or injury; and * On 12/30/21, Staff 5 (LPN) documented on a skin sheet the resident had "dark purple bruising on right side of back below ribcage," which measured 6 cm x 15 cm, and reported the resident could not remember how it happened. There was no additional information about the injury. There was no documented evidence the facility immediately investigated the injury to rule out abuse. The facility did not report the injury to the local SPD office as suspected abuse/neglect. The need to ensure injuries of unknown cause were investigated promptly, and reported if necessary, was discussed with Staff 1 (Administrator) and Staff 2 (RN/Director of Health Services) on 01/25/22. Staff 2 acknowledged there was no documented evidence the facility had investigated the injury to rule out abuse and/or neglect. The facility was asked to report the injury of unknown cause to the local SPD. Confirmation of the report was provided on 01/25/22, prior to exit.

1. All injuries will be investigated and documented on either event report or in progress note or both. 2. Injuries are reported by CG or MA via a form labeled skin sheet regardless of the type of injury (this can include fractures and other injuries) which is forwarded to LN. Unless absent, the LPN assigned to either ALF or MC will investigate the reported injury. Documentation of the injury and treatment plan will be on a "wound/skin issue" sheet in EHR. (In the event of assigned LPN's absence, injuries will be investigated by: remaining LPN, RN, or administrator. Injuries without known cause and where abuse has not been ruled out will be reported to the DHS and administrator for forwarding to APS. 3. Each time an injury is reported where, after investigation, a cause cannot be determined and abuse has not been ruled out. 4. Administrator and/or Director of Health Services

Based on interview and record review, it was determined the facility failed to ensure incidents were promptly investigated to rule out abuse and/or neglect, reviewed by the administrator, and immediately reported to the local Seniors and People with Disabilities (SPD) office if abuse and/or neglect could not reasonably be ruled out for 1 of 1 sampled resident (#7) whose records were reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 7 was admitted to the facility in July 2018 with diagnoses including mixed Alzheimer's and dementia. Review of Resident 7's record identified the following: * On 04/02/22, Resident 7 had expressed unwanted sexualized behaviors towards another resident. The residents were immediately separated. Further record review indicated the incident was not investigated until 04/05/22 through 04/06/22 and was not reported to the local SPD office until 04/06/22. There was no documented evidence the facility administrator reviewed the incident of suspected abuse; and * On 04/06/22, a progress note indicated that Resident 7 displayed unwanted sexualized behaviors towards another resident. There was no documented evidence the facility conducted an immediate investigation of the suspected abuse. In an interview on 04/14/22, Staff 1 (ED), reported that the incident was reported by a third party and Adult Protective Services came into the facility and notified them of the suspected abuse. On 04/14/22, the need to ensure the facility conducted immediate investigations to rule out abuse or suspected abuse, reviewed by the administrator, and to immediately report to the SPD office if abuse and/or neglect could not reasonably be ruled out was discussed with Staff 20 (Administrator). She acknowledged the findings.

Staff to be trained on policy for reporting suspected abuse.  Staff to be informed of what and when to report. All investigations to be completed within 24 hours and if abuse can not be ruled out, a report will be made to the appropriate agency. Staff training to be held on policy of reporting.  Training will be completed upon hire and reviewed yearlyand as needed. RN and Administrator will ensure that training is completed.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and maintained in good repair, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: The kitchen was toured on 01/25/22. The following areas were in need of cleaning and/or repair: * Paper signage posted in multiple areas of kitchen, creating an uncleanable surface; * Loose food debris under and around freezer shelving units; * Dried food buildup and black matter on base of rolling cart in freezer; * Black debris on metal transition strip between kitchen and freezer floors; * Dark gray smudges above and below freezer handle; * Loose food debris on machinery surfaces beneath warewasher; * Multiple areas of paint missing on kitchen back door, creating an uncleanable surface; * Gray smudges on flooring in small dry storage room; * Large area of ceiling cut out in small dry storage room, with white thread of debris hanging down; * Black streaks, scratches, and chipped wood on dining room and kitchen entry doors; * Chipped paint on kitchen and dining room door jambs, creating an uncleanable surface; * Chipped paint on legs of food warmer cart; * Chipped paint on large stand mixer; * Plastic molding detached from base of cabinetry on beverage bar; * Missing caulking on beverage bar, with black debris on counter/backsplash and backsplash/wall seams; * Black matter on beveled edges of beverage bar cabinetry; and * Food debris and black matter inside drawers and cupboards of beverage bar. The areas in need of cleaning and/or repair were reviewed with Staff 1 (Administrator) on 01/25/22. She acknowledged the findings.

1. All documentation/signage placed in sheet protectors. Maintainence notified regarding chipped paint and environmental deficiencies. Interior doors leading to the kitchen were removed. The exterior door will be ordered and replaced. 2. Cleaning schedule initiated. 3. Area checked weekly. 4. Dietary manager and administrator.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 2 of 2 sampled residents (#s 3 and 4) whose evaluations were reviewed. Findings include, but are not limited to: Resident 3 and 4's move-in evaluations were reviewed on 01/25/22.  There was no documented evidence the following required elements were addressed prior to move-in: * Personality, including how the person copes with change or challenging situations; and * Environmental factors that impact the resident's behavior including, but not limited to, noise, lighting, and room temperature. The need to ensure move-in evaluations contained all required elements was discussed with Staff 1 (Administrator) and Staff 2 (RN/Director of Health Services) on 01/25/22. They acknowledged the findings.

1. Move-in evaluation (Oregon Screening Tool--OST) will have all portions completed prior to resident move-in. 2. Screening tool used prior to Feb. 2022 was missing two sections which have since been added to ensure compliance with regulation. 3. The move-in evaluation system will be evaluated with each move-in, and evaluation is reviewed at 30 days, quarterly, and with any significant change of condition. 4. Administrator

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction to staff regarding care and services, were followed by staff and were completed in a timely manner for  3 of 5 sampled residents (#s 1, 3 and 5). Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in November 2017 with diagnoses including dementia. Observations of the resident, interviews with staff and review of the care plan dated 11/13/22, showed the care plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas: * Dressing, toileting and ambulation; * Behaviors, resistance to care; * Meal assistance; * Hoyer lift use and transfers; * Evacuation ability; * Repositioning, bed mobility; and * Pain, making needs known. The need to ensure resident service plans were reflective of current care needs and provided direction to staff  was discussed with Staff 1 (Administrator), Staff 2 (RN/Director of Health Services) and Staff 4 (LPN) on 01/25/22. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 03/2019 with diagnoses including dementia. During the acuity interview on 01/24/22, Resident 5 was identified to have a skin impairment, weight loss and increased confusion. Observations of the resident and interviews with staff from 01/24/22 to 01/25/22, review of the service plan, dated 12/10/22, and temporary service plans indicated the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas: * Current activity interests; * Mental health status and behaviors, including signs and symptoms of depression and effective non-drug interventions; * Level of assistance required with ADLs; * Instructions on when and how often to assist with incontinence care; * Pain status, including interventions; * Skin condition; * Fall risk and interventions; * Frequency of safety checks; * Assistance with choosing food options and health shakes; and * Ability to use call light and pendant. The need to ensure service plans were reflective of resident needs, were accurate, and included clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (RN/Director of Health Services) on 01/25/22. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 12/2022, with diagnoses including Lewy Body Dementia. Resident 3's initial service plan was dated 12/10/22, and his/her 30-day service plan was due on 01/13/22. The facility was unable to provide documented evidence the service plan had been reviewed within 30 days. The need to update service plans in a timely manner was discussed with Staff 1 (Administrator) and Staff 2 (RN/Director of Health Services) on 01/25/22. They acknowledged the findings.

1. Service plans will be completed by due date (upon admission, 30 days, 90 days, and quarterly thereafter). 2. Upon admission to facility, resident will be added to the care plan calendar by RCC to ensure that 30-day assessment and careplan update is not overlooked. All care plan updates will be completed after review of resident, chart notes, and any discussion with family/staff/resident to ensure that care plan accurately reflects resident's current functional ability, care staff are providing, and what interventions are effective, and discontinuing interventions proven to be ineffective. Changes to care plan will not be done via editing a current intervention but by creating a new intervention/instruction with the date it was started. Interventions deemed to no longer be effective will be deleted/archived from the care plan. Interventions for assistance (such as safety checks, frequency of toileting) will be measurable and specific indicating number of times per shift and/or what time during a shift the care should occur. Interventions/instructions will be specific to the individual resident.   3. Each time a care plan requires updating. 4. Administrator and/or Health Services Director

Based on observation, interview and record review, it was determined the facility failed to ensure the RN performed an assessment, developed interventions based on the condition of the resident and updated the service plan for 2 of 3 sampled residents (#s 1 and 5) who experienced significant weight changes. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in November 2017 with diagnoses including dementia.      Weight records dated 07/05/21 to 12/05/21 and progress notes and RN notes dated 10/23/21 through 01/24/22 indicated the resident experienced the following: A 10.6 pound weight gain from 09/05/21 to 10/05/21. This constituted a 10.20% severe weight gain in one month. The resident's weights were monitored at the beginning of each month from September 2021 through January 2022 and ranged between 98-108 pounds. The resident experienced a severe stroke in mid-January, was placed on hospice, and experienced an ongoing rapid decline. Observations of the resident on 01/24/22 and 01/25/22 showed the resident was bed bound and unresponsive. Staff assisted the resident with small sips of water, as well as utilizing a toothette to swab the resident's mouth. No meals were observed. A current weight was not obtained for January 2022, as the resident was actively dying. The resident passed away during the survey. Interviews with staff from 01/24/22 through 01/25/22 indicated the resident was dependent for all care. Staff indicated the resident's intake was very poor since the stroke. The resident was unable to complete any ADLs on his/her own, including food and fluid intake. Staff indicated the resident was more active and able to eat and drink more independently prior to the stroke. The facility failed to ensure an RN assessment was completed for the severe weight gain with documented findings, resident status, and interventions made as a result of the assessment. In an interview on 01/25/22 Staff 2 (RN/Director of Health Services) indicated she believed the weight gain was an error. Staff 2 stated they had a period of time when the scale was not operating correctly. She suspected the resident's weight was inaccurate and a re-weight was not obtained. Staff 2 further stated the resident did not have any acute issue going on at the time that would contribute to a gain. The resident did not have any problems with edema that would have affected his/her weight. Staff 2 indicated she was unable to locate any documentation of a significant change of condition assessment completed regarding the weight or any documentation regarding the potential error. The need to ensure an RN assessment was completed related to significant changes in condition which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (Administrator), Staff 2 (RN/Director of Health Services) and Staff 4 (LPN) on 01/25/22. The staff acknowledged the findings. 2. Resident 5 was admitted to the facility in 03/2019 with diagnoses including dementia, irritable bowel syndrome, and hypothyroidism. The resident's 01/01/22 through 01/24/22 MAR, service plan dated 12/10/21, progress notes dated 10/24/21 through 01/24/21, and weight records from 06/10/21 through 01/18/22 were reviewed, Staff 2 (RN/Director of Health Services) and Staff 5 (LPN) were interviewed. Weight records identified the resident lost 18 lbs. between 9/10/21 - 12/10/21, or 11.9% of his/her total body weight in three months, which represented a significant change of condition and required a timely facility RN assessment. A facility RN assessment was not completed until 01/20/22. The facility had obtained orders on 10/21/21 to provide a nutritional supplement between meals. The record indicated the supplement was currently being provided. A progress note dated 12/23/21 noted the resident was seen by her doctor to follow up on chronic diarrhea and weight loss. Interviews with Staff 2 and Staff 5 indicated they were communicating with the resident's doctor frequently and medication changes were made in an attempt to decrease the side effects of diarrhea and weight loss. During the survey, staff encouraged and assisted the resident to the dining room, and when the resident declined the meal offered, staff provided menu alternatives. On 01/25/22, the need to ensure RN assessments were performed in a timely manner for all residents who had significant changes of condition, interventions were communicated to staff, and service plans were updated was discussed with Staff 1 (Administrator) and Staff 2. They acknowledged the findings.

1. Significant weight changes will be reviewed and documented via significant changes of condition assessment by the RN. Significant changes in ADL function and changes to psychosocial status (behaviors) will be reviewed and documented via significant change of condition assessment by RN. 2. Weights are obtained with monthly vitals by the CG. Weights are reviewed by LPN assigned to unit. Weight variances of 3 or more pounds will generate a re-weight of the resident within 1 business day of discovery of variance which is completed by the LPN. Once per week, LPNs and DHS will meet to review resident concerns. Each unit LPN will report to DHS upon discovery of significant weight change confirmation so that RN can complete significant change of condition within 24-48 hours (1-2 business days). In the event that the scale is broken or weights appear grossly inaccurate, this information will be documented in the resident's chart. Upon repair (recalibration) of scale, weights will be obtained and reviewed per above instructions. Potential significant changes in ADL function and/or changes to psychosocial status will be reviewed at weekly meeting and resident placed on two-week observation period. Within 24-48 hours (1-2 business days) of completion of observation period, RN will determine if signficant change of condition occurred and update the plan of care. 3. As the significant change occurs: within 24-48 hours (1-2 business days). 4. Administrator, RN, LPN

Based on interview and record review, it was determined the facility failed to ensure fire drill records included documentation of all elements required by the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire drill records for 08/2021 through 01/2022 were reviewed on 01/25/22. The fire drill records did not include the following required elements: * Location of simulated fire; * Escape route used; * Problems encountered related to residents who failed to participate in drills; * Evacuation time period needed; and * Number of occupants evacuated. The need to ensure all elements required by the OFC were documented for fire drills was discussed with Staff 1 (Administrator) on 01/25/22. She acknowledged the findings.

1. Fire drill form updated to include required elements. 2. Form updated. 3. Monthly fire drills on alternating shifts. 4. Administrator

Based on interview and record review, it was determined the facility failed to ensure fire drill records included documentation of all required elements. This is a repeat citation. Findings include, but are not limited to: The fire drill record for 04/05/22 was reviewed and did not include the following required elements: * Escape route used; * Problems encountered related to residents who failed to participate in drills; * Evacuation time period needed; and * Number of occupants evacuated. The need to ensure fire drills included documentation of all required elements was discussed with Staff 20 (Administrator) on 04/14/22. She acknowledged the findings.

A new fire drill procedure will be implemented. New policy will clearly state: Date/Time Location Escape route Issues with residents during evacuation Time needed Staff participation Number of residents evacuated. Policy will be reviewed at move in or hire.  Fire drills will be held 6x year. Administrator to ensure that proper policy is followed.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were met. Findings include, but are not limited to: Fire and life safety records, dated 08/21 through 01/22, were reviewed on 01/25/22. There was no documented evidence alternate escape routes were used during fire drills and no documented evidence residents received annual training which included general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting place. The need to ensure all general fire and life safety requirements were met was discussed with Staff 1 (Administrator) on 01/25/22. She acknowledged the findings.

1 & 2. During fire drills, alternate routes will be included.  Safety procedures, evacuation methods and fire drill responsibility will be reviewed with residents or their designee if resident is cognitively impaired during quarterly care conference. 3. Annually 4. Administrator

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained in clean and good repair. Findings include, but are not limited to: Observations of the facility on 01/25/22 showed the following areas were in need of cleaning or repair: * Black streaks and chipped paint on doors and door jambs throughout the Assisted Living Facility and both MCC units, including resident rooms, dining rooms, and elevator; * Chipped paint and small gouges on walls throughout facility, including hallways and bathrooms; * Missing linoleum flooring at seam, approximately 1" x 12", in laundry room, creating an uncleanable surface; * Deep gouge in wall, approximately 3' x 1½" on wall behind reception desk on second floor; * Missing caulking around faucet in bathroom by elevator on second floor, exposing unfinished ceramic and creating an uncleanable surface; * Chipped paint along length of handrail in Memory Care Unit 1 dining room; and * Food debris, stains, and litter inside drawers and cabinetry of Memory Care Unit 1 dining room. The areas in need of cleaning and/or repair were shown to and/or discussed with Staff 1 (Administrator) on 01/25/22 and 01/26/22. She acknowledged the findings.

1. All citations turned over to Maintenance Dept. 2. Maintenance will complete repairs and order supplies as needed. 3. Weekly 4. Administrator/maintenance staff

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained in clean and good repair. This is a repeat citation. Findings include, but are not limited to: Observations of the facility on 04/13/22 and 04/14/22 showed the following: 1. Areas still in need of cleaning or repair from relicensure survey in January 2022: * Black streaks and chipped paint on doors and door jambs throughout the Assisted Living Facility and both MCC units; * Chipped paint and small gouges on walls throughout facility, including hallways and bathrooms; * Chipped wood on dining room entry doors; and * Food debris, stains, and litter inside drawers and cabinetry of Memory Care Unit 1 dining room. 2. Additional areas in need of cleaning or repair: * Exposed nails and broken wall seams on 2nd floor reception desk; * Loose flooring strips in library, creating an uneven surface; * Stains on library fabric chair seats; * Acrylic wall sign holders outside resident rooms hanging or broken; * Food splatters on ceiling in dining area of Memory Care Unit 1; * Dark debris in fluorescent light fixtures in Memory Care Units 1 and 2; * Broken and stained ceiling tiles in Memory Care Units 1 and 2; * Missing ceiling tiles with exposed wires, in Memory Care Unit 2; * Scrapes and gouges on walls throughout Memory Care Unit 2; * Chunk missing from wall, with exposed underwall, by window in common area of Memory Care Unit 2; and * Caulking missing from toilet bases in Memory Care Units 1 and 2, creating an uncleanable surface. The areas in need of cleaning and/or repair were shown to Staff 20 (Administrator) on 04/14/22. She acknowledged the findings.

Monthly checklist will be implemented for administrator to inspect all enviromental areas for need of repair. Areas in need of repair will be reported immediately on maintence log for repair. Repairs will be done monthly and as needed. Administrator and maintenance will be responsible to ensure that all areas are in good repair.

Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to: The building was toured on 01/25/22. Observations and interviews with staff confirmed the two doors leading to the enclosed courtyard from Memory Care Unit 1 failed to have an alarming device to alert staff when residents exited the building. The lack of exit door alarms was discussed with Staff 1 (Administrator) on 01/25/22. Staff 1 acknowledged the findings.

1 & 2. Alarms for doors have been ordered. 3. Daily 4. Administrator and maintenance

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 231, C 240, C 420, C 422, C 613 and C 655.

See Above

Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C231, C420 and C613.

All areas of deficiency will be addressed and corrected.  Administrator will oversee areas and ensure that proper changes or repairs are completed. These areas will be monitored daily until completed, and then ongoing after correction.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 252, C 260 and C 280.

See Above

Based on observation, interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C231, C420 and C613.

The facility will be in compliance with state inspection by 5/29/2022 and ready for re-inspection. Administrator will be responsible for ensuring that all corrections are completed.

The findings of the re-licensure survey, conducted January 24, 2022 through January 25, 2022, 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, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. 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 survey to the relicensure survey of 01/25/22, conducted 04/13/22 through 04/14/22, 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 01/25/22, conducted on 06/14/22, are documented in this report.  It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services.