St Anthony Village

Based on observation, interview, and record review, it was determined the licensee failed to provide effective oversight for the operation of the facility and to ensure the quality of services rendered in the facility. Findings include, but are not limited to:

During the re-licensure survey, conducted 05/12/25 through 05/15/25, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity of the citations.

1. A situation was identified which constituted an immediate threat to the health and safety of the residents in the following area:

OAR 411-057-0155 (3) – Staff Training requirements

OAR 411-054-0045 (1)(f)(B) – RN Delegation and Teaching

OAR 411-054-0070 (9)(b) – Training within 30 days: Direct Care Staff

The facility developed and implemented an immediate plan of correction during the survey to address the threat to residents' safety, and the immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violation.

2. Refer to deficiencies in the report.

OAR 411-054-0025 (1) Facility Administration: Operation

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

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure required postings were displayed in a routinely accessible and conspicuous location for residents and visitors and available for inspection at all times. Findings include, but are not limited to:

The initial tour of the facility was completed on 05/12/25. Observations showed three required postings were not displayed including:

* The name of the administrator, including designee in charge posted by shift or when the administrator was out of the facility;
* Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections; and
* The LGBTQIA2S+ Non-discrimination Notice.

The environmental walkthrough was completed with Staff 1 (Administrator), Staff 9 (Maintenance Supervisor), and Witness 2 (Consultant) on 05/13/25 at 3:00 pm, and the requirement for postings was reviewed.

On 05/15/25 at 1:30 pm, the need to display the required postings was reviewed with Staff 1 and Witness 2. They acknowledged the findings.

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.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to develop and implement a written policy and procedure for resident smoking in accordance with the Oregon Indoor Clean Air Act, ORS 433.835 to 433.875. Findings include, but are not limited to:

During the acuity interview on 05/12/25, the facility stated there were no residents who required assistance with smoking, and residents who smoked independently used a covered smoking area in the parking lot. A copy of the facility smoking policy was requested on 05/12/25 at 10:30 am.

On 5/12/25 at 11:30 am, three unsampled residents were observed smoking cigarettes on the sidewalk less than 10 feet from the building entrance.

Additional observations throughout the survey showed residents smoking inside the smoking area, and also individual residents smoking in locations around the facility property.

The environmental walkthrough was completed with Staff 1 (Administrator), Staff 9 (Maintenance Supervisor), and Witness 2 (Consultant) on 05/13/25 at 3:00 pm. During the walkthrough, multiple cigarette butts were discovered outside the facility entrance and exit doors, along with burned wooden matches and cigarette ashes.

During the walkthrough, Staff 1 acknowledged they could not provide a written policy for smoking other than residents should smoke in the designated area.

The need to ensure the community implemented a written policy and procedure on smoking in accordance with the Oregon Indoor Clean Air Act, ORS 433.835 to 433.875 was discussed with Staff 1 and Staff 9 on 05/15/25 at 1:30 pm. They acknowledged the findings.

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.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to maintain complete and accurate records for 4 of 6 sampled residents (#s 3, 4, 5 and 6) and one unsampled resident whose records were requested. Findings include, but are not limited to:

Facility records for Residents 3, 4, 5 and 6 were reviewed during survey and found to be incomplete and/or inaccurate in the following areas:

* Residents 3, 4, 5, and 6 lacked updated quarterly evaluations, updated quarterly service plans and/or an initial service plan;
* Resident 5 lacked an RN assessment for a significant change of condition;
* Resident 6 lacked signed physician orders; and
* Resident 6 and an unsampled resident lacked documentation of signed Residency Agreements (a document that must be provided to a resident at move-in).

The need to ensure resident records were complete and accurate was discussed with Staff 1 (Administrator) and Witness 2 (Consultant) during the exit interview on 05/15/25 at 5:25 pm. They acknowledged the findings.

Refer to C252, C260, C280

OAR 411-054-0025 (8) Facility Administration: Records

(8) RECORDS. The facility must ensure the preparation, completeness, accuracy, and preservation of resident records.
(a) The facility must develop and implement a written policy that prohibits the falsification of records.
(b) Unless required or allowed by state or federal law, a facility shall not disclose any personally identifiable information regarding:
(A) A resident’s sexual orientation;
(B) Whether a resident is LGBTQIA2S+;
(C) A resident’s gender transition status; or (D) A resident’s human immunodeficiency virus status.
(c) The facility shall take appropriate steps to minimize the likelihood of inadvertent or accidental disclosure of information described in subsection (b) of this section to other residents, visitors or facility staff, except to the minimum extent necessary for facility staff to perform their duties. Facilities must notify residents or resident representatives if a resident is affected by a disclosure of information.
(d) Resident records must be kept for a minimum of three years after the resident is no longer in the facility.
(e) Upon closure of a facility, the licensee must provide the Department with written notification of the location of all records.
Name:

This Rule is not met as evidenced by:

Based on interview and record review, it was determined, the facility failed to conduct an ongoing quality improvement program that evaluated services, resident outcomes, and resident satisfaction. Findings include, but are not limited to:

a. During an interview with Staff 1 (Administrator) and Staff 7 (Director of Care and Nursing) on 05/15/25 at 3:51pm, it was confirmed the facility had an initial quality improvement meeting in 06/2024, subsequent meetings were held in 07/2024 and 08/2024 however; there was no documented evidence the facility continued the quality improvement meetings after 08/2024.

b. During the re-licensure survey, conducted 05/12/25 through 05/15/25, the quality improvement plan to ensure adequate resident care, services, and satisfaction was found to be ineffective based on the number and severity of the citations.

Refer to the deficiencies in the report.

OAR 411-054-0025 (9) Facility Administration: Quality Improvement

(9) QUALITY IMPROVEMENT PROGRAM. The facility must develop and conduct an ongoing quality improvement program that evaluates services, resident outcomes, and resident satisfaction.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure residents’ right to a homelike environment and to be treated with dignity and respect for multiple unsampled residents residing in the community. Findings include, but are not limited to:

Observations of resident corridors were made at 9:03 am on 05/12/25. Several signs and two neon lights featuring adult content topics such as nudity and sexually suggestive content were observed outside of Room 103, covering the door, as well as portions of the walls to the left and to the right of the door.

Interviews with unsampled residents on 05/15/25 revealed the following statements regarding the adult content signs:

* “I hate it, it offends me, but [they] just say [it’s] free speech”;
* “I dislike them very much. They’re practically pornography”;
* “I’ve just been told not to go down there, so I avoid that hall now”;
* “They upset me so much, just walking by them”;
* “I think it’s offensive and disrespectful to everyone living here”; and
* “[I]t’s gotten worse. It’s like pornography all over our walls.”

The need to ensure residents’ right to dignity, respect, and a homelike environment was discussed with Staff 1 (Administrator) on 05/15/25 at 8:23 am. She acknowledged the findings.

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.

This Rule is not met as evidenced by:

?Based on interview and record review, it was determined the facility failed to ensure resident-to-resident altercations were immediately reported to the local Seniors and People with Disability (SPD) office for 2 of 2 sampled residents (#s 1 and 3) who had resident-to-resident altercations. Findings include, but are not limited to:

1. Resident 1 moved into the endorsed MCC in 03/2022 with diagnoses including dementia, diabetes mellitus type two and peripheral artery disease.

Observations of the resident, interviews with staff, and review of the resident's 03/02/25 service plan, 03/22/25 through 05/02/25 temporary service plans, progress notes and incident investigations were completed.

A review of the resident's records showed the following:

* 04/29/25 - Staff documented in a progress note that Resident 1 was punched on the left side of the face by an unsampled resident.

There was no documented evidence the facility had immediately reported the incident to the local SPD office, as suspected abuse.

In an interview on 05/12/25 at 2:30 pm, Staff 3 (LPN/Director of the Cottages) indicated she was unaware of the incident and confirmed the altercation had not been reported nor had an investigation been completed. Staff 3 reported the incident to the local SPD office and provided confirmation of the report on 05/14/25.

The need to ensure incidents of abuse or suspected abuse were immediately reported to the local SPD office was discussed with Staff 1 (Administrator), Staff 3, and Witness 2 (Consultant) on 05/15/25 at 2:30 pm They acknowledged the findings.

?2. Resident 3 moved into the facility in 04/2022 with diagnoses including stroke.

The resident’s 02/12/25 to 05/12/25 progress notes were reviewed, and the following was identified:

* A 02/27/25 progress note indicated Resident 3 was involved in a verbal altercation with an unsampled resident.

Documentation that the altercation had been reported to the local SPD office and a copy of the facility investigation was requested at 2:03 pm on 05/13/25. Staff 2 (LPN) stated the altercation had not been reported nor had it been investigated. Survey requested the facility report the incident and confirmation was received at 3:03 pm on 05/14/25.

The need to report all resident-to-resident altercations to the local SPD office was discussed with Staff 1 (Administrator) and Witness 2 (Consultant) on 05/15/25 at 8:23 am. They acknowledged the findings.

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.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure the initial evaluation addressed all required elements to develop an initial service plan to meet the resident's needs, evaluations were performed with significant changes of condition and/or at least quarterly and available to staff for 4 of 6 sampled residents (#s 3, 4, 5 and 6) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 5 moved into the assisted living community in 12/2016 with diagnoses including type 2 diabetes, vascular dementia and aphasia due to cerebrovascular accident (stroke).

Review of Resident 5’s clinical record revealed the following:

* The most recent evaluation was completed on 01/12/24; and
* A significant change of condition occurred due to a right wrist fracture on 03/26/25.

In an interview on 05/13/25 at 11:10 am, Staff 2 (LPN) confirmed there was no documented evidence an evaluation had been completed with the significant change of condition or that a quarterly evaluation had been completed after 01/12/24.

The need to ensure evaluations were completed with a significant change of condition and/or quarterly was reviewed with Staff 1 (Administrator) and Witness 2 (Consultant) on 05/15/25 at 1:45 pm. They acknowledged the findings.

?2. Resident 4 moved into the assisted living community in 05/2018 with diagnoses including schizoaffective disorder, diabetes, and dehydration.

Review of Resident 4’s clinical record revealed the most recent quarterly evaluation was completed on 03/07/2024.

In an interview on 05/14/25, Staff 4 (Resident Services Director) confirmed there was no documented evidence of quarterly evaluations completed after that date.

The need to ensure evaluations were completed quarterly was reviewed with Staff 1 and Witness 2 (Consultant) on 05/15/25 at 1:45 pm. They acknowledged the findings.

3. Resident 3 moved into the assisted living community in 04/2022 with diagnoses including stroke, chronic obstructive pulmonary disease, hypertension, and atrial fibrillation.

Review of the resident’s clinical record revealed the most recent quarterly evaluation was completed on 08/16/24.

In an interview on 05/14/25, Staff 2 (LPN) confirmed there were no quarterly evaluations completed after that date.

The need to ensure evaluations were completed quarterly was reviewed with Staff 1 (Administrator) and Witness 2 (Consultant) on 05/15/25 at 1:45 pm. They acknowledged the findings.

4. Resident 6 moved into the assisted living community in 04/2025 with diagnoses including anxiety.

The resident’s initial evaluation lacked the following elements:

* Pronouns; and
* Gender Identity.

The need to ensure initial evaluations included all required elements, as indicated by the resident, was discussed with Staff 1 (Administrator) on 05/12/25 at 3:15 pm and Staff 4 at 12:38 pm. They acknowledged the findings.

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

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

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

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

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

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

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

This Rule is not met as evidenced by:

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

1. Resident 1 moved into the endorsed MCC 03/2022 with diagnoses including dementia, diabetes mellitus type two and peripheral artery disease.

Observations of the resident, interviews with staff, and review of the resident's most recent service plan, dated 03/02/25, showed the service plan did not provide clear direction to staff or was not reflective of the resident's current needs in the following areas:

* Transfers;
* Eating;
* Bathing;
* Communication; and
* Palliative care.

Observations and interviews with staff, and temporary service plans dated 04/09/25 showed the service plan was not implemented in the following areas:

* Use of gait belt for transfers; and
* Resident 1’s heels were not floated with a pillow while sleeping.

The need to ensure service plans were reflective of resident's current care needs, provided clear direction to staff, and services were implemented was discussed with Staff 1 (Administrator), Staff 3 (LPN/Director of the Cottages) and Witness 2 (Consultant) on 05/15/25 at 2:30 pm. They acknowledged the findings.

?2. Resident 5 moved into the assisted living community in 12/2016 with diagnoses including type two diabetes, vascular dementia, and aphasia due to cerebrovascular accident.

Observations of the resident, interviews with staff and resident and review of the resident’s most recent service plan, dated 09/24/24, were completed.

The following areas were not reflective of residents’ current care needs and/or failed to provide clear directions to staff regarding the delivery of services:

* Mobility/fall risk devices related to cane use;
* Delegated tasks;
* Toileting;
* Preferences related to gender of staff person providing care; and
* Behaviors related to resistance to care and interventions for staff.

The need to ensure service plans were completed following quarterly evaluations, were reflective of the resident's care needs and provided clear instruction to staff was discussed with Staff 1 (Administrator) and Witness 2 (Consultant) on 05/15/25 at 1:45 pm. The findings were acknowledged.

3. Resident 3 moved into the assisted living community in 04/2022 with diagnoses including stroke, chronic obstructive pulmonary disease, hypertension, and atrial fibrillation, and was identified in the acuity interview as receiving hospice services.

The resident’s 05/07/25 service plan and temporary service plans were reviewed, observations of the resident were made, and interviews with staff were conducted.

The resident’s service plan was not reflective of his/her preference to have the door of his/her apartment open at all times.

The need to ensure the service plan was reflective of resident preferences was discussed with Staff 1 (Administrator) and Witness 2 (Consultant) on 05/15/25 at 8:23 am. They acknowledged the findings.

4. Resident 6 moved into the assisted living community in 04/2025 with diagnoses including anxiety.

Review of a “New Move-in” temporary service plan (TSP) dated 04/09/25 included some information regarding the resident’s care and services. However, it lacked clear direction regarding the delivery of services and did not include a written description of who should provide the services and what, when, how, and how often the services should be provided.

The resident’s initial service plan and 30-day update was not completed and accessible to staff, as required.

During an interview on 05/12/25 at 12:38 pm, Staff 4 (Resident Services Director) reported the service plan had not been completed and showed this writer a copy of evaluation notes dated 05/01/25. Staff 4 reported she was currently entering information into the initial service plan. Staff 4 completed the initial service plan and provided survey with a copy on 05/12/25 at 4:03 pm.

The need to ensure service plans were completed at move-in, provided clear direction for staff regarding the delivery of services and were accessible to staff was discussed with Staff 1 (Administrator), Staff 7 (Director of Care and Nursing) and Witness 3 (Consultant) on 05/12/25 at 3:15 pm. They acknowledged the findings.

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

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

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

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, at least one other staff person who was familiar with or who was going to provide services to the resident and a licensed nurse if the resident needed, or was receiving nursing services for 4 of 6 sampled residents (#s 3, 4, 5 and 6) whose service plans were reviewed. Findings include, but are not limited to:

Resident 3, 4, 5 and 6's current service plans were reviewed during the survey.

The service plans lacked evidence a Service Planning Team reviewed and participated in the development of the service plans. In an interview on 05/14/25 at 11:45 am, Staff 4 (Resident Services Director) confirmed there was no documented evidence of a service planning team.

The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Administrator) and Witness 2 (Consultant) on 05/15/25 at 1:45 pm. They acknowledged the findings.

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.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure resident-specific instructions or interventions were developed for short-term changes of condition, the interventions were communicated to the staff and made part of the resident record, and the condition was monitored at least weekly through resolution for 3 of 6 sampled residents (#s 2, 4 and 6) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 2 moved into the endorsed MCC in 02/2023 with diagnoses including dementia and major depression disorder.

The resident's current service plan dated 03/05/25, progress notes dated 02/12/25 through 05/12/25, and corresponding temporary service plans were reviewed. Interviews with caregivers were completed between 05/12/25 and 05/15/25.

a. The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts and progress noted at least weekly through resolution:

* 03/20/25 – Discoloration to right hand and upper arm and left arm;
* 03/27/25 – Skin tear to left thigh; and
* 04/11/25 – Puree diet order.

The need to ensure actions or interventions were determined and documented for short term changes of condition, written communication of a resident's change of condition and any required interventions to staff on all shifts, and documentation of staff instructions or interventions were made part of the resident record with weekly progress noted until the condition resolved was discussed with Staff 1 (Administrator), Staff 3 (LPN/Director of the Cottages) and Witness 2 (Consultant) on 05/15/25 at 2:55 pm. The findings were acknowledged.

?2. Resident 4 moved into the assisted living community in 05/2018 with diagnoses including schizoaffective disorder, diabetes, and dehydration.

The resident's current service plan dated 03/2024, progress notes dated 02/12/25 through 05/12/25, and corresponding temporary service plans were reviewed. Interviews with caregivers were completed between 05/12/25 and 05/15/25.

a. The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the actions or interventions to staff on all shifts and progress noted at least weekly through resolution:

* 02/18/25 - progress note: “cleaned and bandaged a wound on left ring finger”;
* 04/09/25 - progress note: Resident 4 found “lying on floor bleeding from a wound to the right eye and forehead also had carpet scratches on both knees”; and
* 04/17/25 - progress note: “refused to have dressing removed after removing their stitches”.

The need to ensure actions or interventions were determined and documented for short-term changes of condition, written communication of a resident's change of condition and any required interventions to staff on all shifts, and documentation of staff instructions or interventions were made part of the resident record with weekly progress noted until the condition resolved was discussed with Staff 1 (Administrator) and Witness 2 (Consultant) on 05/15/25 at 1:30 pm. They acknowledged the findings.

3. Resident 6 moved into the assisted living community in 04/2025 with diagnoses including urine retention. During the acuity interview the resident was identified with using a Foley catheter.

Charting notes (the tool used by the facility to monitor changes of condition) dated 04/10/25 through 04/14/25, temporary service plans (TSP’s) and the 04/10/25 through 05/11/25 MARs were reviewed during the survey.

The following short-term changes of condition were identified:

* On 04/17/25 - The 04/2025 MAR noted nitrofurantoin microcrystal 100 mg capsules, twice daily to treat and prevent urinary tract infections was discontinued.

There was no documented evidence the facility determined what action or intervention was needed for the resident, communicate the intervention to staff on each shift and monitor the condition at least weekly through resolution.

The need to ensure actions or interventions were determined and documented for short term changes of condition, written communication of a resident's change of condition and any required interventions to staff on all shifts, and documentation of staff instructions or interventions were made part of the resident record with weekly progress noted until the condition resolved was discussed with Staff 1 (Administrator), Staff 7 (Director of Care and Nursing) and Witness 2 (Consultant) on 05/12/25 at 3:15 pm. They acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure significant changes of condition were assessed by a facility RN for 1 of 1 sampled resident (#5) reviewed for significant changes of condition. Findings include, but are not limited to:

Resident 5 moved into the assisted living community in 12/2016 with diagnoses which included type two diabetes, vascular dementia and aphasia due to cerebrovascular accident.

During the entrance conference on 05/12/25, Resident 5 was identified as having had a recent fall with right wrist fracture.

Review of the clinical record revealed the resident fell on 03/26/25 which resulted in a fracture of the right wrist which caused a decline in ADL functioning. Interviews with staff and the resident throughout the survey confirmed Resident 5 was independent with ADL function prior to the right wrist fracture and required ADL assistance in the areas of dressing and bathing following the right wrist fracture.

The decline in ADL functioning constituted a significant change of condition for which an assessment by the facility RN was required.

There was no documented evidence the facility RN conducted an assessment.

During an interview on 05/13/25 at 11:10 am Staff 2 (LPN) confirmed the facility was without an RN at the time the significant change of condition occurred, and no RN assessment was conducted.

The need to ensure the facility RN completed an assessment timely when a resident experienced a significant change of condition was discussed with Staff 1 (Administrator) and Witness 2 (Consultant) on 05/15/25 at 1:45 pm. They acknowledged the findings.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure delegation and teaching was provided and documented by a RN in accordance with the Oregon Administrative Rules (OAR) adopted by the Oregon State Board of Nursing (OSBN) in chapter 851, division 047 for 2 of 2 sampled residents (#s 1 and 5) who received subcutaneous injections by a facility unregulated assistive person (UAP). UAP /MT's #s 14,15, 23, 24, and 29 documented insulin administration for residents #s 1 and 5 and multiple unsampled residents who were prescribed insulin. The UAP's were not delegated to perform insulin administration which put the residents at risk for serious harm. Findings include, but are not limited to:

Pursuant to OAR chapter 851 division 006, delegation process means the process utilized by an RN to authorize an UAP to perform a nursing procedure for a client, the outcome of which the RN retains accountability for. The RN must document all delegation process decisions, actions and outcomes pursuant to OAR 851-045 including comprehensive assessment, reasoned conclusions that identify client problems and risks, educate the UAP and evaluate their learned knowledge, and provide a one-on-one education and evaluation experience with the UAP and the client.

Resident 5's MARs from 04/01/25 through 05/12/25 revealed subcutaneous injections had been given once weekly by Staff 14 (CG/MT) and Staff 15 (MT).

Review of the nursing delegation binder found no documented evidence delegation had been completed for Staff 14 (CG/MT) and Staff 15 (MT).

Additionally, the RN comprehensive assessment to determine Resident 5’s condition was stable and predictable, one of the criteria for delegation of a nursing procedure, was not completed and/or documented.

During the acuity interview on 05/12/25, Staff 5 (RN) was identified by facility staff to be the RN holding delegation at the facility. Documented evidence of Staff 5 having taken over delegation was not available. Staff 5 was not present during the survey for interview.

There was no documented evidence Staff 14 and Staff 15 had been delegated to administer Trulicity (for diabetes) by subcutaneous injection for Resident 5. This put the resident at serious risk for harm.

An immediate plan of correction was requested on 05/14/25. The facility provided a plan of correction on 05/14/25 at 4:25 pm, prior to survey exit. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation.

The need to ensure nursing delegation and teaching to facility UAPs was provided and documented by a RN in accordance with the Oregon Administrative Rules (OAR) adopted by the Oregon State Board of Nursing (OSBN) in chapter 851, division 047 was reviewed with Staff 1 (Administrator) and Witness 2 (Consultant) on 05/15/25 at 1:45 pm. They acknowledged the findings.

2. Resident 1 moved into the endorsed MCC in 03/2022 with diagnoses including dementia, diabetes mellitus type two and peripheral artery disease.

Resident 1's MARs from 04/01/25 through 05/12/25 revealed subcutaneous injections had been given once nightly by Staff 23 (CG/MT), Staff 24 (MT) and Staff 29 (MT).

Review of the nursing delegation binder found no documented evidence delegation had been completed for Staff 23 (CG/MT), Staff 24 (MT) and Staff 29 (MT).

During an interview with Staff 1, Staff 6, and Staff 7 on 05/14/25 at 9:15 am, confirmation was received there were no employee delegation records for any MTs.

There was no documented evidence Staff 23, 24, and 29 had been delegated to administer insulin glargine (for diabetes) by subcutaneous injection for Resident 1. This put the resident at serious risk for harm.

An immediate plan of correction was requested on 05/14/25. The facility provided a plan of correction on 05/14/25 at 4:25 pm, prior to survey exit. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation.

The need to ensure nursing delegation and teaching to facility UAPs was provided and documented by a RN in accordance with the Oregon Administrative Rules (OAR) adopted by the Oregon State Board of Nursing (OSBN) in chapter 851, division 047 was reviewed with Staff 1 (Administrator) and Witness 2 (Consultant) on 05/15/25 at 1:45 pm. They acknowledged the findings.

OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching

(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:(B) Delegation and Teaching. Delegation and teaching must be provided and documented by a RN in accordance with the Oregon Administrative Rules adopted by the Oregon State Board of Nursing in chapter 851, division 047.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment for 1 of 1 sampled resident (#1) during ADL care and multiple unsampled residents during meal service. Findings include, but are not limited to:

1. Resident 1 moved into the endorsed MCC in 03/2022 with diagnoses including dementia, diabetes mellitus type two and peripheral artery disease.

During the acuity interview, Resident 1 was identified as a two-person assist for incontinence care and transfers.

During an ADL observation on 05/12/25 at 1:50 pm the following was noted:

* Two staff donned gloves and assisted the resident in bed with incontinence care which included cueing, wiping, change of clothing and bed linens;
* Two staff rolled the resident side to side to provide assistance with removal of a soiled incontinence brief;
* One staff provided perineal care. Staff then touched a clean incontinence brief, t-shirt, pants and socks. Staff sat the resident at the edge of bed, grabbed the back waistband of Resident 1’s pants, hoisted the resident up and transferred him/her into the wheelchair wearing the soiled gloves;
* One staff changed the bed linens wearing the soiled gloves;
* One staff then pushed the resident in wheelchair with one hand and carried the unbagged soiled brief in the other hand into the dining area wearing the soiled gloves;
* The staff members removed the soiled gloves and were not observed to have performed hand hygiene before resuming duties.

Maintaining effective infection prevention and control while providing ADL care was reviewed with Staff 1 (Administrator), Staff 3 (LPN/Director of the Cottages) and Witness 2 (Consultant) on 05/15/25 at 2:30 pm. They acknowledged the findings

?2. Observations of meal delivery service were conducted on 05/12/25 and 05/13/25 and identified the following:

* Staff were not observed performing hand hygiene in between delivering meals to resident apartments; and
* Staff were observed pouring beverages into residents’ personal cups and mugs, with the rim of the cup or mug making contact with the beverage container.

In an interview on 05/14/25 at 9:49 am, Staff 10 (Dietary Supervisor) stated the personal cups and mugs were washed by caregiving staff in the residents’ apartments and confirmed there was no way to ensure they were sanitized.

The need to ensure infection prevention and control practices during meal delivery services was discussed with Staff 1 (Administrator) and Witness 2 (Consultant) on 05/15/25 at 8:23 am. They acknowledged the findings.

3. Observations of snack and meal service were completed between 05/13/25 and 05/14/25 in The Cottages MCC and revealed the following:

* Multiple care staff served food and provided occasional direct feeding assistance to residents without donning a protective barrier over potentially contaminated clothing; and
* Multiple care staff were observed to serve residents lunch and touch residents and their chairs and/or wheelchairs, cueing and providing assistance to initiate intake, refill resident beverages, and remove dirty dishes without performing hand hygiene in between dirty and clean tasks or before assisting other residents.

The need to establish and maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment was discussed with Staff 1 (Administrator), Staff 3 (LPN/Director of the Cottages) and Witness 2 (Consultant) on 05/15/25 at 2:55 pm. They acknowledged the findings.

OAR 411-054-0050(1-5) Infection Prevention & Control

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure a safe medication and treatment system was in place and failed to ensure adequate professional oversight of the medication and treatment administration systems. Residents were put at risk related to failure to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, to have an effective system for tracking controlled substances, to follow or have physician orders, to ensure proper use of PRN psychoactive medications, and a system to complete demonstrated competency staff training in medication administration. Findings include, but are not limited to:

During the re-licensure survey, conducted 05/12/25 through 05/15/25, administrative oversight of the facility's medication system was found to be ineffective based on deficiencies in the following areas:

* C 282: RN Delegation and Teaching;
* C 302: Systems: Tracking Controlled Substances;
* C 303: Systems: Medication and Treatment Orders;
* C 330: Systems: Psychotropic Medications;
* C 372: Training within 30 days: Direct Care Staff; and
* Z 155: Staff Training Requirements.

On 05/14/25 at 1:45 pm the survey team requested an immediate plan of correction to address the issues identified. At 4:25 pm, a plan was received and accepted by the survey team prior to exit. The immediate risk was addressed however, the facility will need to evaluate the overall system failures associated with the licensing violation.

Failure to ensure a safe medication system and to ensure adequate professional oversight based on deficiencies related to medication administration was discussed with Staff 1 (Administrator), Staff 3 (LPN/Director of the Cottages) and Witness 2 (Consultant) on 05/15/25 at 2:55 pm. They acknowledged the findings.

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments

(1) MEDICATION AND TREATMENT ADMINISTRATION SYSTEMS. The facility must have safe medication and treatment administration systems in place that are approved by a pharmacist consultant, registered nurse, or physician.(a) The administrator is responsible for ensuring adequate professional oversight of the medication and treatment administration system.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure a system to track controlled substances for 2 of 3 sampled residents (#s 1 and 3) who were administered PRN narcotics. Findings include, but are not limited to:

1. Resident 3 moved into the assisted living community in 04/2022 with diagnoses including osteoarthritis, stroke, chronic obstructive pulmonary disease, hypertension, and atrial fibrillation, and was identified in the acuity interview as receiving hospice services.

The resident’s 04/01/25 to 05/12/25 MARs, Controlled Substance PRN Disposition log and current prescriber orders were reviewed, and the following was identified:

The resident had an order for morphine, give 0.5 ml every hour as needed for chest pain and/or generalized pain.

* The log indicated morphine was administered three times on 05/06/25. There were only two entries on the MAR for that day. The log lacked time administered for two of the three entries.
* The MAR indicated the morphine was administered on 05/07/25 at 3:29 pm and on 05/09/25 at 2:45 pm. There were no corresponding entries for the morphine administration on the log for those dates/times.
* The log indicated morphine was administered at 10:00 pm on 05/10/25. There was no corresponding entry on the MAR.
* The log indicated morphine was administered four times on 05/11/25. The MAR only had two entries for the same date.
* One entry on the log for 05/11/25 lacked an administration time.
* The log indicated morphine was administered at 8:00 am and 9:25 am on 05/12/25. There were no corresponding entries on the MAR for these times.

During an interview at 11:58 am on 05/14/25, Staff 11 (MT) stated MTs counted narcotics at each shift change, reviewed entries for discrepancies, and notified Staff 2 (LPN) immediately of any discrepancies. During an interview at 10:03 am on 05/15/25, Staff 2 stated she had not been notified by staff of any discrepancies regarding the above morphine prescription.

The need to ensure a system for tracking controlled substances was discussed with Staff 1 (Administrator) and Witness 2 (Consultant) on 05/15/25 at 8:23 am. They acknowledged the findings.

?2. Resident 1 moved into the endorsed MCC in 03/2022 with diagnoses including dementia, diabetes mellitus type two and peripheral artery disease.

The current written prescriber orders and MARs dated 04/01/25 through 05/12/25 were reviewed during the survey.

Resident 1 had a physician order for morphine 0.5 mls, by mouth every hour as needed for pain/shortness of breath at end of life.

Review of the MARs and Controlled Substance PRN Disposition Log revealed the following discrepancies:

* There were three times a facility staff signed the Controlled Substance PRN Disposition log indicating the morphine was removed from locked storage but did not document on the MAR that the PRN medication was administered.

* There was one time facility staff signed the Controlled Substance PRN Disposition log indicating the morphine was removed once from locked storage but documented on the MAR that the PRN medication was administered two times.

The need to ensure the tracking of controlled substances was accurate was reviewed with Staff 1 (Administrator), Staff 3 (LPN/Director of the Cottages) and Witness 2 (Consultant) on 05/12/25 at 2:30 pm. They acknowledged the findings.

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances

(e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments that the facility was responsible to administer and/or to ensure written orders were administered as prescribed for 3 of 6 sampled residents (#s 3, 5 and 6) whose MARs and physician orders were reviewed. Findings include, but are not limited to:

1. Resident 6 moved into the assisted living community in 04/2025 with diagnoses including urine retention and anxiety. During the acuity interview on 05/12/25 it was reported the resident used a Foley catheter.

The resident’s clinical record was reviewed on 05/12/25 and the following was identified:

* There was no documented evidence the facility obtained written and signed move-in orders for the resident; and
* On 04/17/25 there was no discontinue order for scheduled nitrofurantoin microcrystal 100 mg capsules, twice daily to treat and prevent urinary tract infections.

During interviews with Staff 2 (LPN) on 05/12/25 through 05/14/25, signed orders were requested. No further information was provided.

The need to ensure the facility had a system to obtain signed physician orders before a resident moved in and to ensure physician orders were obtained for any subsequent medication or treatment changes was discussed with Staff 1 (Administrator), Staff 2, Staff 7 (Director of Care and Nursing) and Witness 2 (Consultant) on 05/12/25 at 3:15 pm. They acknowledged the findings.

?2. Resident 3 moved into the assisted living community in 04/2022 with diagnoses including stroke, high blood pressure, and atrial fibrillation.

The resident’s 04/01/25 to 05/12/25 MARs and current physician orders were reviewed, and the following was identified:

The resident had an order for isosorbide mononitrate (for high blood pressure), take one tablet every morning and hold for systolic blood pressure of less than 110. The MAR indicated the medication was administered when the systolic blood pressure was less than 110 on 11 occasions between 04/05/25 and 05/11/25.

The need to ensure orders were administered as prescribed was discussed with Staff 1 (Administrator) and Witness 2 (Consultant) on 05/15/25 at 8:23 am. They acknowledged the findings.

3. Resident 5 moved into the assisted living community in 12/2016 with diagnoses including type two diabetes, vascular dementia and aphasia due to cerebrovascular accident (stroke).

The resident's 04/01/25 to 05/12/25 MARs and physician orders dated 04/08/25 were reviewed. The following was identified:

Resident 5 had an order for Trulicity (for diabetes), 0.5 mils to be administered under the skin once a week. On 05/09/25 the MAR noted “med not given.” In an interview on 05/14/25 at 9:00 am, Staff 2 (LPN) confirmed Trulicity was not given on 05/09/25 as the medication could not be found.

The need to ensure all written, signed orders from a legally recognized practitioner were carried out as prescribed was discussed with Staff 1 (Administrator) and Witness 2 (Consultant) on 05/15/25 at 1:45 pm. They acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure the MAR had written resident-specific parameters, failed to provide the common side effects of the medications and when to contact a health professional regarding side effects and document non-pharmacological interventions had been tried with ineffective results prior to administering a PRN psychotropic medication for 3 of 4 sampled residents (#s 1, 2 and 6) who had orders for PRN psychotropics. Findings include, but are not limited to:

1. Resident 1 moved into the endorsed MCC in 03/2022 with diagnoses including dementia, diabetes mellitus type two and peripheral artery disease.

The resident was prescribed lorazepam (sedative to treat anxiety), 0.25 mls - every 4 hours as needed for anxiety and haloperidol (a psychotropic medication to treat delirium and nausea) 1 ML every 2 hours as needed for nausea at end of life.

* The MAR did not provide instructions to non-licensed staff regarding how the resident demonstrated signs and symptoms of anxiety behaviors for which staff could consider administering the medication;
* There were no resident-specific non-pharmacological interventions; and
* The MAR lacked common side effects of the medications and lacked instructions for when to contact a health professional regarding side effects.

The need to have written, resident-specific parameters for PRN psychotropic medications, and to have non-drug interventions for staff to attempt and document ineffective results prior to administration of the psychotropic medications, was reviewed with Staff 1 (Administrator), Staff 3 (LPN/Director of the Cottages) and Witness 2 (Consultant) on 05/15/25 at 2:30 pm. They acknowledged the findings.

?2. Resident 2 moved into the endorsed MCC in 02/2023 with diagnoses including dementia and major depressive disorder.

The resident's 04/01/25 to 05/15/25 MARs, progress notes and current physician orders were reviewed. The following was identified:

* Resident 2 had an order for lorazepam 0.5mg, administer one tablet by mouth every four hours as needed for nausea/vomiting/anxiety/agitation/restlessness. The MARs indicated staff had not administered the medication; and
* On 05/15/25 at 12:32 pm, Staff 22 (MT) confirmed there were no resident-specific parameters, side effects, or non-pharmacological interventions documented in the electronic MAR.

The need to include resident-specific parameters, common side effects, and non-pharmacological interventions on the MAR for all PRN psychotropic medications was reviewed with Staff 1 (Administrator), Staff 3 (LPN/Director of the Cottages) and Witness 2 (Consultant) on 05/15/25 at 2:55 pm. They acknowledged the findings.

3. Resident 6 moved into the assisted living community in 04/2025 with diagnoses including anxiety.

The resident’s 04/01/25 through 05/11/25 MARs were reviewed on 05/12/25 and the following was identified:

* The resident was prescribed hydroxyzine HCL 50 mg tablet, as needed for anxiety; and
* The MAR lacked non-pharmacological interventions to attempt and document as ineffective prior to administering the as needed psychotropic medication.

The resident was not administered the as needed medication during the review period.

The need to ensure staff were instructed on non-pharmacological interventions to attempt and document as ineffective prior to administering an as needed psychotropic medication was discussed with Staff 1 (Administrator), Staff 7 (Director of Care and Nursing) and Witness 2 (Consultant) on 05/12/25 at 3:15 pm.

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

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was thoroughly assessed by an RN, PT or OT and evaluated quarterly for 1 of 3 residents (#3) who had supportive devices with potentially restraining qualities. Findings include, but are not limited to:

Resident 3 moved into the assisted living community in 04/2022 with diagnoses including stroke, chronic obstructive pulmonary disease, hypertension, and atrial fibrillation, and was identified in the acuity interview as receiving hospice services.

The resident’s 08/16/24 service plan and quarterly evaluation, 05/07/24 hospice service plan, and temporary service plans were reviewed, and observations of the resident were made. The following was identified:

Observations of the resident’s room on 05/12/25 showed the resident had a hospital bed with bilateral quarter-length side rails in the up position. Review of the service plan indicated the resident used the side rails for mobility.

There was no documented evidence a thorough assessment of the side rails had been completed by an RN, PT, or OT. In an interview at 2:03 pm on 05/13/25, Staff 2 (LPN) confirmed there was no assessment completed.

The last quarterly evaluation for the resident was completed on 08/16/24. Therefore, the side rails were not evaluated on a quarterly basis.

The need to ensure supportive devices with potentially restraining qualities were assessed by an RN, PT, or OT and evaluated on a quarterly basis was discussed with Staff 1 (Administrator) and Witness 2 (Consultant) on 05/15/25 at 8:23 am. They acknowledged the findings.

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents per the facility’s Acuity-Based Staffing Tool (ABST) and posted staffing plan. Findings include, but are not limited to:

a. The assisted living community was home to 72 residents with three separate floors and an endorsed MCC with two separate and locked units (North and South Cottages). Both cottages combined had a total of 22 residents.

b. The facility ABST questionnaire completed by Staff 1 (Administrator) on 05/12/25 identified the following:

* One resident in assisted living and two residents in memory care required 2-person care and/or transfers;
* 12 residents required assistance with behavioral symptoms; and
* Eight residents required assistance due to cognitive decline.

c. Review of the facility's posted staffing plan and current ABST data from 05/01/25 through 05/07/25 indicated the following:

* Day Shift: 6:00 am to 2:00 pm – 2 MT’s and 3 CG’s in Assisted Living and 1 MT and 4 CG’s in memory care ;
* Swing Shift : 2:00 pm to 10:00 pm - 2 MT’s and 3 CG’s in Assisted Living and 1 MT and 4 CG’s in memory care; and
* Overnight Shift: 1 MT and 2 CG’s in assisted Living and 2 CG’s in memory care (one CG in each locked and separate cottage); and
* Seven of seven days reviewed were not staffed to the posted staffing plan.

Following the review of the facility ABST and posted staffing plan it was determined the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents, including sufficient staff in the memory care units for two-person transfers and emergency evacuation needs.

The need to ensure the facility had sufficient staff per the ABST, posted staffing plan and resident acuity was discussed with Staff 1 (Administrator), Staff 7 (Director of Care and Nursing) and Witness 2 (Consultant) on 05/13/25 at 1:15 pm. They acknowledged the findings.

Refer to C 362 and C 363.

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

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility’s Acuity-Based Staffing Tool (ABST) did not accurately capture care time and care elements that staff were providing to each resident as outlined in each individual service plan for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5 and 6). Findings include, but are not limited to:

A review of ABST documentation, interviews and observations throughout the survey were completed. The following was identified:

* The minutes recorded on the ABST did not match services provided by staff in multiple areas for Residents 1, 2, 3, 4, 5 and 6.

The need for the ABST to accurately capture care time and care elements that staff were providing to each resident was discussed with Staff 1 (Administrator) and Witness 2 (Consultant) on 05/15/25 at 1:45 pm. They acknowledged the findings.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) was updated whenever there was a significant change of condition and/or no less than quarterly for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5, and 6). Findings include, but are not limited to:

The facility’s ABST data was reviewed at 12:02 pm on 05/12/25. The ABST data for 6 of 6 sampled residents did not show documented evidence of being updated at least quarterly.

The need to ensure residents’ ABST was updated no less than quarterly was discussed with Staff 1 (Administrator), Staff 3 (LPN/Director of the Cottages) and Witness 2 (Consultant) on 05/15/25 at 2:55 pm. They acknowledged the findings.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan

(4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule.
(a) Before a resident moves in.
(b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b).
(c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034.

(5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST:
(a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule.
(b) Staffing plan must account for unscheduled care needs.
(c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week.
(d) The staffing requirements outlined in OAR 411-054-0070(1).
(e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.)
(f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift.
(g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area.
(h) The staffing needs required under the Specific Needs Contracts, if applicable.

(6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract:
(A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents.
(B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST.
(b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST.
(c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure 7 of 7 sampled MTs (#s 11,12,13,15, 23, 24, and 27) and multiple unsampled MTs demonstrated knowledge and performance in abdominal thrust and first aid training prior to providing care and services to residents. This put residents at risk for serious harm. Findings include, but are not limited to:

On 05/14/25 at 9:15 am survey requested competency training records which included first aid and abdominal thrust training for the following MTs:

* Staff 15, hired 03/17/25;
* Staff 24, hired 03/18/25; and
* Staff 27, hired 04/29/25.

During an interview on 05/14/25 at 9:52 am, Staff 7 (Director of Care and Nursing) reported there were no competency training records for any of the newer staff.

On 05/14/25 at 10:38 am, MT competency training records including abdominal thrust and first aid training were requested for the following long-term MTs:

* Staff 11, hired 01/20/15;
* Staff 12, hired 02/25/08;
* Staff 13, hired 04/20/15; and
* Staff 23, hired 12/16/15.

During an interview on 05/14/25 at approximately 12:32 pm, Staff 1 (Administrator) stated, “we don’t have any competency training, for anyone.”

The lack of documented competency training records for the above MTs put residents at risk for serious harm related to potential choking incidents and medication and treatment errors.

On 05/14/25 at 1:45 pm, the survey team requested an immediate plan of correction (POC) to ensure direct care staff whose job it was to perform first aid and abdominal thrust were trained by appropriate facility staff and there was documentation to show they had observed and evaluated the direct care staff’s ability to perform the task. On 05/14/25 at approximately 4:25 pm, the facility submitted a POC that was accepted by the survey team.

The immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violation.

The need to ensure the facility had a process to ensure all direct care staff had documentation of demonstrated competency in any duty they were assigned, including abdominal thrust and first aid was discussed with Staff 1 and Witness 3 (Consultant) on 05/14/25 at 1:52 pm. They acknowledged the findings.

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff

(5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF.
(a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned.
(b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to:
(A) The role of service plans in providing individualized resident care.
(B) Providing assistance with the activities of daily living.
(C) Changes associated with normal aging.
(D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition.
(E) Conditions that require assessment, treatment, observation and reporting.
(F) General food safety, serving and sanitation.
(G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised.

(9) ADDITIONAL REQUIREMENTS. Staff:
(a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services.
(b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required.
(c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed.

(10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule.
(a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and recorded according to Oregon Fire Code (OFC) and fire and life safety instruction was provided to staff on alternate months from fire drills. Findings include, but are not limited to:

Six months of facility fire drills and fire and life safety records from 11/2024 to 05/2025 were requested and reviewed on 05/13/25 and revealed the following:

a. The facility lacked documented evidence unannounced fire drills were conducted and recorded at least every other month.

b. Staff 1 (Administrator) confirmed on 05/13/25 at 11:25 am there was no documented evidence staff were trained in fire and life safety instruction on alternate months from fire drills.

The need to ensure fire drills were conducted per OFC and staff were trained in fire and life safety instruction on alternate months from fire drills was discussed with Staff 1 and Witness 2 (Consultant) on 05/15/25 at 12:20 pm. They acknowledged the findings.

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

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

This Rule is not met as evidenced by:

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 at least annually. Findings include, but are not limited to:

Fire and life safety records were reviewed and discussed with Staff 1 (Administrator) on 05/13/25 at 11:25 am.

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 again at least annually.

The need to ensure fire and life safety instruction was provided to each resident within 24 hours of admission and again annually was discussed with Staff 1 and Witness 2 (Consultant) on 05/15/25 at 1:45 pm. They acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure emergency fire exits including stairways, halls, passageways and exits remained unobstructed. Findings include, but are not limited to:

The posted fire evacuation map of the facility showed there were four stairwells in the facility, and they would be used to evacuate the 2nd and 3rd floor residents to the ground level fire exits in the event of an emergency evacuation.

The initial tour of the facility was completed on 05/12/25. Observations showed stored items partially obstructing all four stairwells and fire exits including:

* Two trash cans in use;
* Two bed frames and mattresses;
* Two housekeeping carts;
* Three six-foot-long folding tables;
* Six new and unused trash cans;
* Two carpet extractors;
* A powered wheelchair;
* A shower bench;
* A four wheeled walker;
*Two bed side rails; and
* A one-foot ladder.

The environmental walkthrough was completed with Staff 1 (Administrator), Staff 9 (Maintenance Supervisor), and Witness 2 (Consultant) on 05/13/25 at 3:00 pm. During the walkthrough, the partially obstructed fire exits were acknowledged by Staff 1 and Staff 9.

On 05/15/25 at 1:30 pm, fire egresses were observed unobstructed. The requirement to ensure emergency fire exits remained unobstructed was discussed with Staff 1 and Witness 2. They acknowledged the findings.

OAR 411-054-0090 (6-7) Fire and Life Safety: Egress, first aid

(6) UNOBSTRUCTED EGRESS. Stairways, halls, doorways, passageways, and exits from rooms and the building must be unobstructed.
(7) FIRST AID SUPPLIES. First aid supplies must be provided, properly labeled, and readily accessible.

This Rule is not met as evidenced by:

Based on observation, interview and record review, it was determined the facility failed to submit a plan of correction that satisfied the Department. This is a repeat citation. Findings include, but are not limited to:

Refer to Z 155

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval

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

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure the use of extension cords was not allowed. Findings include, but are not limited to:

The initial environmental tour was completed on 05/12/25. Observations showed an electrical outlet outside of Room 101 with an extension cord duct taped into the outlet, then duct taped to the floor of the hallway leading toward Room 103, then attached to a multi plug electrical tap.

The environmental walkthrough was completed with Staff 1 (Administrator), Staff 9 (Maintenance Supervisor), and Witness 2 (Consultant) on 05/13/25 at 3:00 pm. During the walkthrough, the duct taped extension cord and tap were acknowledged by staff.



On 05/15/25 at 1:30 pm, the requirement to ensure extension cords were not used was discussed with Staff 1 and Witness 2. They acknowledged the findings.

OAR 411-054-0300 (10) Electrical Systems

(10) ELECTRICAL SYSTEMS.
(a) WIRING SYSTEMS. All wiring systems must meet the building codes in effect at the date of installation and devices shall be maintained and in good repair.
(b) The use of extension cords and other special taps is not allowed.
(c) LIGHTING. Each unit must have general illumination in the bath, kitchen, living space, and sleeping area. The general lighting intensity in the unit for way finding must be at least 20-foot candles measured from the floor.
(A) Lighting in the unit bathroom must be at least 50-foot candles measured from the height of the hand-wash basin and three feet above the shower floor with the curtain open.
(B) Task lighting at the unit food preparation or cooking area must be at least 50-foot candles measured from counter height.
(C) Corridor lighting must equal a minimum of 20-foot candles measured from the floor.
(D) Table height lighting in the dining room must equal a minimum of 25-foot candles without light from windows.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure the residents' right to be treated with dignity and respect and to receive services in a manner that protects privacy and dignity for 1 of 1 resident (#1) during ADL care. Findings include, but are not limited to:

Resident 1 moved into the memory care with diagnoses including type 2 diabetes, peripheral artery disease and dementia.

During the acuity interview, Resident 1 was identified as a two-person assist for incontinence care.

During an ADL observation on 05/12/25 at 1:50 pm the following was noted:

* Two staff were observed providing Resident 1 with incontinence care and failed to close the shutter of the window looking into the resident’s room;
* An unsampled resident was observed peeking through the window into the resident’s room and knocking on the window during incontinent care;
* The unsampled resident opened Resident 1’s door during incontinent care and said, “What’s going on here?”

The need to ensure residents' rights of privacy and dignity were upheld was discussed with Staff 1 (Administrator), Staff 3 (LPN/Director of the Cottages) and Witness 2 (Consultant) on 05/15/25 at 2:30 pm. They acknowledged the findings.

OAR411-004-0020(2)(d) Individual Privacy: Own Unit

(2) Provider owned, controlled, or operated residential settings must have all of the following qualities:
(d) Each individual has privacy in his or her own unit.

This Rule is not met as evidenced by:

Based on observation, interview and record review, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their units. Findings include, but are not limited to:

During the survey from 05/12/25 through 05/15/25, observations and interviews with residents and staff confirmed not all residents in memory care had keys to their units.

In an interview on 05/15/25 at 10:32 am, Staff 1 (Administrator) indicated they did not routinely give every resident in the memory care a key to their units.

The need to ensure all residents were provided keys to their units was discussed with Staff 1 on 05/15/25 at 10:32 am. She acknowledged the findings.

OAR411-004-0020(2)(e) Individual Door Locks: Key Access

(2) Provider owned, controlled, or operated residential settings must have all of the following qualities:
(e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit.

This Rule is not met as evidenced by:

Based on observation and interview, the facility failed to post the Resident Rights and Protections, as described in OAR 411-054- 0027, and the LGBTQIA2S+ nondiscrimination notice. Findings include, but are not limited to:

The initial tour of the facility was completed on 05/12/25. Observations showed two required postings were not displayed:

* Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections; and
* The LGBTQIA2S+ Non-discrimination Notice.

The need to ensure required postings were displayed in a routinely accessible and conspicuous location for residents and visitors, and available for inspection at all times was discussed with Staff 1 (Administrator), Staff 9 (Maintenance Supervisor), and Witness 2 (Consultant) on 05/13/25 at 3:00 pm.

Refer to C 152.

OAR 411-054-0025 (5)(f)(g) 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:

(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.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure an initial evaluation addressed all required elements, including pronouns and gender identity for 1 of 1 sampled resident (#6) whose initial evaluation was reviewed. Findings include, but are not limited to:

Refer to C252.

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation

(1) INITIAL SCREENING AND MOVE-IN.

(c) Each resident record must, before move-in and when updated, include the following information:

(B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity.

(5) The resident evaluation must address the following elements:

(a) For service planning purposes, if indicated by the resident,

(A) Name

(B) Pronouns.

(C) Gender identity.

This Rule is not met as evidenced by:

?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:

A situation was identified which constituted an immediate threat to the health and safety of the residents in the following area:

OAR 411-054-0070 (9)(b) – Training within 30 days: Direct Care Staff

Refer to: C 150, C 152, C 154, C155, C 156, C 200, C 231, C 295, C 372, C 420, C 422, C 427, C 650.

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.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure 12 of 12 newly hired and long-term direct care staff (#s 11,12,13,15,18, 19, 21, 23, 24, 25, 27 and 29) completed pre-service orientation, pre-service dementia training and had demonstrated knowledge and performance in any duty they were assigned prior to providing care and services to residents. Seven of 12 staff were identified MTs who were observed working independently passing medications and treatments. The MTs lacked documentation of competency in medication and treatment administration, which put residents at risk for serious harm. Findings include, but are not limited to:

Employee training records were reviewed on 05/14/25 at 12:15 pm.

a. On 05/14/25 at 9:15 am survey requested competency training records for the following staff:

* Staff 15 (MT), hired 03/17/25;
* Staff 24 (MT), hired 03/18/25;
* Staff 27 (MT), hired 04/29/25;
* Staff 18 (CG), hired 03/15/25;
* Staff 25 (CG) hired 02/01/25;
* Staff 21 (CG) hired 03/15/25; and
* Staff 19 (CG) hired 12/02/24.

During an interview on 05/14/25 at 9:52 am, Staff 7 (Director of Care and Nursing) reported there were no competency training records for any of the newer staff.

On 05/14/25 at 10:38 am MT competency training records for the following long-term MTs were requested:

* Staff 11, hired 01/20/15;
* Staff 12, hired 02/25/08;
* Staff 13, hired 04/20/15; and
* Staff 23, hired 12/16/15.

During an interview on 05/14/25 at approximately 12:32 pm, Staff 1 (Administrator) stated, “we don’t have any competency training, for anyone.”

The lack of documented competency training records for the above MTs put residents at risk for serious harm related to potential medication and treatment errors.

On 05/14/25 at 1:45 pm, the survey team requested an immediate plan of correction (POC) to ensure MTs whose job it was to administer medications to residents were trained by appropriate facility staff and there was documentation to show they had observed and evaluated the MTs’ ability to perform safe medication administration unsupervised. On 05/14/25 at approximately 4:25 pm, the facility submitted a POC that was accepted by the survey team.

The immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violation.

b. Staff 11,12,13,15,18, 19, 21, 23, 24, 25 and 27 lacked the following additional competency training requirements, pre-service orientation and pre-service dementia training requirements in one or all of the following areas:

* Written job description;
* Resident rights;
* Abuse reporting;
* Fire safety and emergency procedures;
* Infectious disease prevention;
* HCBS;
* Department approved LGBTQIA2S+ training;
* Pre-service dementia care training;
* Environmental factors that are important to a resident’s well being;
* Family support and the role of the family;
* How to provide personal care to a resident with dementia;
* Supportive devices with restraining qualities;
* Role of the service plan in providing individualized care;
* Providing assistance with ADL’s;
* Changes associated with normal aging;
* Identification, documentation and reporting of changes of condition;
* Conditions that require assessment, treatment, observation and reporting; and
* General food Safety, serving and sanitation.

c. Annual in-service training records were reviewed for Staff 11, 12, 13, 23 and Staff 29 (CG), hired 06/21/20, and the following was identified:

All five long term direct care staff lacked documented evidence 16 hours of annual in-service training, which included at least 6 hours in dementia care topics, was completed.

The need to ensure the facility had a process to ensure all direct care staff had documentation of pre-service orientation prior to beginning any job duties, pre-service dementia training prior to providing care and services independently, had demonstrated competency in any duty they were assigned, including additional medication training for MTs and to ensure annual in-service hours were completed was reviewed with Staff 1 (Administrator) on 05/14/25 at 12:23 pm. She acknowledged the findings.

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.

This Rule is not met as evidenced by:
Based on interview, and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 30, 31, 32 and 33) completed all required pre-service orientation, 3 of 3 staff (#s 30, 32 and 33) completed pre-service dementia training and 2 of 2 staff (#s 30 and 33) completed competency training within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:


1.The facility’s training records were reviewed on 10/07/25 with Staff 1 (Administrator) and Staff 7 (Director of Care and Nursing). The following was identified:


a. Staff 30 (Med Tech), hired 08/10/25, Staff 31 (Housekeeper), hired 09/12/25), Staff 32 (CG) hired 09/18/25 and Staff 33 (CG) hired 08/13/25.

There was no documented evidence the staff had completed orientation and the pre-service training on one or more of the following required topics:

* Resident rights and values and CBC care;

* Abuse reporting requirements;

* Fires safety and emergency procedures;

* Infectious Disease Preventions; and

* Approved HCBS course.


b. Staff 30 (Med Tech), Staff 32 (CG) and Staff 33 (CG).

There was no documented evidence the staff had completed the pre-service dementia training on one or more of the following required topics:

* Dementia disease process including progression of the disease, memory loss and psychiatric & behavioral symptoms;

* Techniques for understanding, communicating and responding to distressful behavioral symptoms;

* Strategies for addressing social needs and engaging person with dementia in meaningful activities;

* Specific aspects of dementia care and ensuring safety f residents with dementia including addressing pain, providing food/fluids, preventing wandering, sue of person-centered approach;

* Environmental factors that are important to a resident’s well-being (e.g. staff interactions, lighting, room temperature, noise, etc.);

* Family support and the role the family may have in the care of the resident;

* How to recognize behaviors that indicate a change in the resident’s condition and report behaviors that require on-going assessment;

* How to provide personal care to a resident with dementia, including an orientation to the resident’s service plan; and

* Use of supportive deices with restraining qualities in memory care communities.


c. Staff 30 (Med Tech) and Staff 33 (CG).

There was no documented evidence staff had demonstrated competency in one or more of the following required topics:

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

* Conditions that require assessment, treatment, observation and reporting; and

* General food safety, serving and sanitation.


The facility failed to ensure all required training was completed and staff demonstrated competency was discussed with Staff 1, Staff 7 and Witness 2 on 10/07/25 at 12:00 pm. They acknowledged the findings.

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.

This Rule is not met as evidenced by:
Based on interview, and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 30, 31, 32 and 33) completed all required pre-service orientation, 3 of 3 staff (#s 30, 32 and 33) completed pre-service dementia training and 2 of 2 staff (#s 30 and 33) completed competency training within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:


1.The facility’s training records were reviewed on 10/07/25 with Staff 1 (Administrator) and Staff 7 (Director of Care and Nursing). The following was identified:


a. Staff 30 (Med Tech), hired 08/10/25, Staff 31 (Housekeeper), hired 09/12/25), Staff 32 (CG) hired 09/18/25 and Staff 33 (CG) hired 08/13/25.

There was no documented evidence the staff had completed orientation and the pre-service training on one or more of the following required topics:

* Resident rights and values and CBC care;

* Abuse reporting requirements;

* Fires safety and emergency procedures;

* Infectious Disease Preventions; and

* Approved HCBS course.


b. Staff 30 (Med Tech), Staff 32 (CG) and Staff 33 (CG).

There was no documented evidence the staff had completed the pre-service dementia training on one or more of the following required topics:

* Dementia disease process including progression of the disease, memory loss and psychiatric & behavioral symptoms;

* Techniques for understanding, communicating and responding to distressful behavioral symptoms;

* Strategies for addressing social needs and engaging person with dementia in meaningful activities;

* Specific aspects of dementia care and ensuring safety f residents with dementia including addressing pain, providing food/fluids, preventing wandering, sue of person-centered approach;

* Environmental factors that are important to a resident’s well-being (e.g. staff interactions, lighting, room temperature, noise, etc.);

* Family support and the role the family may have in the care of the resident;

* How to recognize behaviors that indicate a change in the resident’s condition and report behaviors that require on-going assessment;

* How to provide personal care to a resident with dementia, including an orientation to the resident’s service plan; and

* Use of supportive deices with restraining qualities in memory care communities.


c. Staff 30 (Med Tech) and Staff 33 (CG).

There was no documented evidence staff had demonstrated competency in one or more of the following required topics:

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

* Conditions that require assessment, treatment, observation and reporting; and

* General food safety, serving and sanitation.


The facility failed to ensure all required training was completed and staff demonstrated competency was discussed with Staff 1, Staff 7 and Witness 2 on 10/07/25 at 12:00 pm. They acknowledged the findings.

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.

This Rule is not met as evidenced by:
Based on interview, and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 30, 31, 32 and 33) completed all required pre-service orientation, 3 of 3 staff (#s 30, 32 and 33) completed pre-service dementia training and 2 of 2 staff (#s 30 and 33) completed competency training within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:


1.The facility’s training records were reviewed on 10/07/25 with Staff 1 (Administrator) and Staff 7 (Director of Care and Nursing). The following was identified:


a. Staff 30 (Med Tech), hired 08/10/25, Staff 31 (Housekeeper), hired 09/12/25), Staff 32 (CG) hired 09/18/25 and Staff 33 (CG) hired 08/13/25.

There was no documented evidence the staff had completed orientation and the pre-service training on one or more of the following required topics:

* Resident rights and values and CBC care;

* Abuse reporting requirements;

* Fires safety and emergency procedures;

* Infectious Disease Preventions; and

* Approved HCBS course.


b. Staff 30 (Med Tech), Staff 32 (CG) and Staff 33 (CG).

There was no documented evidence the staff had completed the pre-service dementia training on one or more of the following required topics:

* Dementia disease process including progression of the disease, memory loss and psychiatric & behavioral symptoms;

* Techniques for understanding, communicating and responding to distressful behavioral symptoms;

* Strategies for addressing social needs and engaging person with dementia in meaningful activities;

* Specific aspects of dementia care and ensuring safety f residents with dementia including addressing pain, providing food/fluids, preventing wandering, sue of person-centered approach;

* Environmental factors that are important to a resident’s well-being (e.g. staff interactions, lighting, room temperature, noise, etc.);

* Family support and the role the family may have in the care of the resident;

* How to recognize behaviors that indicate a change in the resident’s condition and report behaviors that require on-going assessment;

* How to provide personal care to a resident with dementia, including an orientation to the resident’s service plan; and

* Use of supportive deices with restraining qualities in memory care communities.


c. Staff 30 (Med Tech) and Staff 33 (CG).

There was no documented evidence staff had demonstrated competency in one or more of the following required topics:

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

* Conditions that require assessment, treatment, observation and reporting; and

* General food safety, serving and sanitation.


The facility failed to ensure all required training was completed and staff demonstrated competency was discussed with Staff 1, Staff 7 and Witness 2 on 10/07/25 at 12:00 pm. They acknowledged the findings.

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.

This Rule is not met as evidenced by:
Based on interview, and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 30, 31, 32 and 33) completed all required pre-service orientation, 3 of 3 staff (#s 30, 32 and 33) completed pre-service dementia training and 2 of 2 staff (#s 30 and 33) completed competency training within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:


1.The facility’s training records were reviewed on 10/07/25 with Staff 1 (Administrator) and Staff 7 (Director of Care and Nursing). The following was identified:


a. Staff 30 (Med Tech), hired 08/10/25, Staff 31 (Housekeeper), hired 09/12/25), Staff 32 (CG) hired 09/18/25 and Staff 33 (CG) hired 08/13/25.

There was no documented evidence the staff had completed orientation and the pre-service training on one or more of the following required topics:

* Resident rights and values and CBC care;

* Abuse reporting requirements;

* Fires safety and emergency procedures;

* Infectious Disease Preventions; and

* Approved HCBS course.


b. Staff 30 (Med Tech), Staff 32 (CG) and Staff 33 (CG).

There was no documented evidence the staff had completed the pre-service dementia training on one or more of the following required topics:

* Dementia disease process including progression of the disease, memory loss and psychiatric & behavioral symptoms;

* Techniques for understanding, communicating and responding to distressful behavioral symptoms;

* Strategies for addressing social needs and engaging person with dementia in meaningful activities;

* Specific aspects of dementia care and ensuring safety f residents with dementia including addressing pain, providing food/fluids, preventing wandering, sue of person-centered approach;

* Environmental factors that are important to a resident’s well-being (e.g. staff interactions, lighting, room temperature, noise, etc.);

* Family support and the role the family may have in the care of the resident;

* How to recognize behaviors that indicate a change in the resident’s condition and report behaviors that require on-going assessment;

* How to provide personal care to a resident with dementia, including an orientation to the resident’s service plan; and

* Use of supportive deices with restraining qualities in memory care communities.


c. Staff 30 (Med Tech) and Staff 33 (CG).

There was no documented evidence staff had demonstrated competency in one or more of the following required topics:

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

* Conditions that require assessment, treatment, observation and reporting; and

* General food safety, serving and sanitation.


The facility failed to ensure all required training was completed and staff demonstrated competency was discussed with Staff 1, Staff 7 and Witness 2 on 10/07/25 at 12:00 pm. They acknowledged the findings.

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.

This Rule is not met as evidenced by:

Based on observation, interview and record review it was determined the facility failed to ensure health care services were provided in accordance with the licensing rules of the facility. Findings include, but are not limited to:

A situation was identified which constituted an immediate threat to the health and safety of the residents in the following area:

OAR 411-054-0045 (1)(f)(B) – RN Delegation and Teaching

Refer to: C 252, C 260, C 262, C 270, C 280, C 282, C 300, C 302, C 303, C 330, C 340, C 360, C 362, C 363 .

OAR 411-057-0160(2b) Compliance with Rules Health Care

(b) Health care services provided in accordance with the licensing rules of the facility.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure activity evaluations and individualized activity plans were completed for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1 and 2's service plans offered some information about the residents' interests, but the facility had not fully evaluated the residents' activity needs in one or more of the following areas:

* Current abilities and skills;
* Emotional and social needs and patterns;
* Physical abilities and limitations;
* Adaptations necessary for the resident to participate; and
* Activities which could be used as behavioral interventions, if necessary.

There were no resident-specific activity plans developed from activity evaluations which detailed what, when, how, and how often staff should offer and assist the resident with more individualized activities.

The need to ensure activity evaluations were completed for all residents, and individualized activity plans developed and implemented was discussed with Staff 1 (Administrator), Staff 3 (LPN/Director of the Cottages) and Witness 2 (Consultant) on 05/15/25 at 2:30 pm. They acknowledged the findings.

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.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to have a written facility policy which detailed when residents had access to the outdoor recreation area and when the doors would be locked. Findings include, but are not limited to:

Observations of the facility interior on 05/12/25 at 11:00 am revealed the courtyard doors were locked, preventing residents from accessing the outdoor recreation area. The weather at the time of the observation was cloudy and approximately 60 F.

On 05/12/25 at 11:00 am, the MCC caregivers were asked and were not aware of when the doors were to be locked or unlocked and who was responsible for unlocking them.

In an interview on 05/12/25 at 12:30 pm, Staff 1 (Administrator) and Staff 3 (LPN/Director of the Cottages) acknowledged there was not a written policy for when MCC residents could access the courtyard.

On 05/15/25 at 1:30 pm the need to have a written policy which described under what circumstances the doors to the courtyard would be locked to limit resident access was discussed with Staff 1 (Administrator) and Witness 2 (Consultant). They acknowledged the findings.

OAR 411-057-0160(g) Outside Area

(g) Access to secured outdoor space and walkways which allow residents to enter and return without staff assistance, except when indicated by OAR 411-057-0170(5)(e).

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure fencing surrounding the perimeter of the outdoor recreation area was maintained. Findings include, but are not limited to:

At 11:45 am on 05/12/25, a tour of the outdoor recreation areas showed a six-foot tall wood fence around the perimeter of the area to prevent elopement, supported by four-inch by four-inch wood posts every six feet.

At least five of the fence posts had broken off, leaving a 30-foot section of fence leaning into the yard, supported from collapse only by a tree branch it had fallen into and was leaning against.

Other sections of fence showed boards cracked and broken off, with large gaps and spaces. The gate was loosely attached with gaps large enough to place an arm through.

At 12:15 pm, Staff 1 (Administrator), Staff 9 (Maintenance Supervisor), Staff 3 (LPN/Director of the Cottages) and Witness 2 (Consultant) were brought to the MCC yard to observe the condition of the fence. They acknowledged the fence was not secure.

Staff 1 and Witness 2 stated they would prevent residents from entering the outdoor recreation area until repairs could be completed.

Observations on 05/12/25 at 4:15 pm showed six new posts had been driven into the ground to support the fence, a rope with an anchor post was attached to prevent further lean, and the areas of missing and broken boards had new boards attached.

In an interview on 05/15/25 at 1:30 pm the need to maintain the MCC secure fence in functional condition was discussed with Staff 1 and Witness 2. They acknowledged the findings.

OAR 411-057-0170(6) Secure Outdoor Recreation Area

(6) SECURE OUTDOOR RECREATION AREA. The memory care community must comply with facility licensing requirements for outdoor recreation areas as well as the following standards. These requirements apply to newly endorsed, constructed, or remodeled communities which have construction documents approved on or after November 1, 2010 with the exception of subsections (d) and (e) of this section. (a) The space must be a minimum of 600 square feet or 15 square feet per resident, whichever is greater and is exclusive of normal walkways and landscaping. The space must have a minimum dimension of 15 feet in any direction; (b) Fences surrounding the perimeter of the outdoor recreation area must be no less than six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition; (c) Walkways must meet the accessibility requirements of the Oregon Structural Specialty Code. Walkway surfaces must be a medium to dark reflectance value to prevent glare from reflected sunlight; (d) Outdoor furniture must be sufficient weight, stability, design, and be maintained to prevent resident injury or aid in elopement; and (e) Doors to the outdoor recreation area may be locked during nighttime hours or during severe weather per facility policy.

This Rule is not met as evidenced by:

The findings of the on-site investigation, conducted 02/10/25, 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, OARs 411 Division 57 for Memory Care Communities. Abbreviations possibly used in this document:ADL: activities of daily livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered Nurse

Based on interview and record review, conducted during a site visit on 02/10/25, the facility's failure to carry out medication and treatment orders as prescribed was substantiated for 1 of 1 sampled resident (# 1). Findings include, but are not limited to:A review of Resident 1's physician orders dated 04/10/24, MAR dated 04/01/24 - 04/30/24 and chart notes dated 12/16/23 - 07/15/24 which indicated the following:· On 04/06/24 at 8:30 am [Resident 1] was placed on alert for receiving wrong medications. Resident 1 received midodrine, aspirin, and senna docusate. RN notified and PCP faxed;· Resident 1 had PRN orders for senna plus for constipation, scheduled order for low dose aspirin for cardiac health, and no order for midodrine.In an interview on 02/10/25, Staff 1 (Administrator) stated s/he recalled this occurrence, and the staff member involved no longer worked for the facility.The facility's failure to carry out medication and treatment orders as prescribed was substantiated.Findings were reviewed and acknowledged by Staff 1 on 02/10/25.Facility Verbal Plan of Correction: The staff member was removed from the medication cart and was restricted to caregiving.

Based on interview and record review, conducted during a site visit on 02/10/25, the facility's failure to fully implement and update an acuity-based staffing tool was substantiated for 2 of 2 sampled residents (#s 3 and 4). Findings include, but are not limited to:Resident 3's service plan dated 09/06/24 and ABST last updated 10/25/24, had not been updated in the last quarter.Resident 4's service plan dated 08/28/24 and ABST last updated 10/25/24, had not been updated in the last quarter.Four residents were listed on the resident roster and lived in the facility that were not entered into the ABST.An unsampled resident moved into the facility on 02/03/25 and had an incomplete ABST profile on 02/10/25.In an interview on 02/10/25, Staff 1 (Administrator) stated s/he had forgotten that resident ABST profiles needed to have at least one item updated and saved to reflect the quarterly update. S/he also stated s/he had started to update the unsampled residents ABST profile but had not gotten back to completing it.A review of the facility's posted staffing plan indicated the following:· Day Shift: ALF - 2 Med techs and 4 Caregivers, MCC - 1 Med tech and 4 caregivers;· Swing Shift: ALF - 2 Med techs and 4 Caregivers, MCC - 1 Med tech and 4 caregivers; and· Night Shift: ALF - 1 Med-tech and 2 Caregivers, MCC - 2 Caregivers.A review of the facility staffing from 02/04/25 - 02/10/25 indicated the facility was not consistently staffed to the posted staffing plan.The facility failed to adopt an acuity-based staffing tool to determine appropriate staffing levels.The findings were reviewed with and acknowledged by Staff 1 on 02/10/25.

The findings of the kitchen inspection, conducted 12/07/23, 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.
The findings of the revisit to the kitchen inspection of 12/07/23, conducted 02/22/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.


The findings of the second revisit to the kitchen inspection of 12/07/23, conducted 06/27/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.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.

The findings of the third revisit to the kitchen inspection of 12/07/23, conducted 08/06/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation, interview, and record review, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:On 12/07/23 at 10:15 am, the facility's kitchen was toured, and food preparation and food delivery was observed. a. Food spills, splatters, debris, dust and dirt was observed on, inside, around or underneath the following: * Flooring edges and base trim throughout the kitchen;* Walls throughout the kitchen;* Ceiling vents throughout the kitchen;* Ceiling tiles throughout the kitchen;* Stainless steel shelving throughout the kitchen;* Legs of stainless steel shelving throughout the kitchen;* Drains throughout the kitchen;* Ice machine grate;* Cabinets under steam table;* Wall and pipes behind the stove and ovens;* Chains suspending the warming lamp of the steam table;* Caulking near warewasher;* Industrial can opener;* French fry slicer;* Kitchen Aid mixer;* Walk-in refrigerator fan guard and surrounding surfaces;* Microwave;* Blenders;* Handles of spice cabinet;* Radio mounted under spice cabinet;* Stand-up mixer; and* Fans throughout the kitchen.b. The following equipment was in need of repair:* Trim and corner guards throughout the kitchen were lifted, broken or missing;* Ceiling tiles with holes near entrance to dining room;* Door frame to dining room had gouged wood and chipped paint;* Sealant of previously repaired floor near drink station was worn;* Clean dish racks had peeling and chipped sealant;* Non-stick coating on frying pans was worn;* Temperature gauge of warewasher was broken;* Cabinets under the steam table had exposed wood and a broken handle;* Laminate of shelving was lifted under microwave;* Stand-up mixer coating was chipped;* Stainless steel three tiered cart had a broken handle;* White cutting board had brown marks and was warped; and* Walk-in freezer door was broken with frozen condensation lining the exterior edges.c. Multiple food items in the dried storage were open to air.d. Staff lacked good infection control related to the use of aprons for caregivers serving food, hand hygiene during food preparation, hand hygiene between dirty and clean tasks, and use of gloves.The need to ensure the kitchen was clean, in good repair, and infection control processes were followed in accordance with the Food Sanitation Rules OAR 333-150-000 was discussed with Staff 1 (Administrator) and Staff 2 (Dining Services Director) on 12/07/23. They acknowledged the findings.
Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:On 02/22/24 at 1:33 pm, the facility's kitchen was toured and food service was observed. a. Food spills, splatters, debris, dust and dirt was observed on, inside, around or underneath the following: * Flooring edges and base trim throughout the kitchen;* Walls throughout the kitchen;* Ceiling vents throughout the kitchen;* Ceiling tiles throughout the kitchen;* Stainless steel shelving throughout the kitchen;* Legs of stainless steel shelving throughout the kitchen;* Multiple food service carts;* Ice machine grate and air vents;* Cabinets under steam table;* Wall and pipes behind the stove and ovens;* Chains suspending the warming lamp of the steam table;* Caulking around warewasher area and wall underneath warewash and sprayer sink;* Industrial can opener;* Kitchen Aid mixer;* Walk-in refrigerator fan guard and surrounding surfaces;* Microwave;* Blenders;* Conveyor toaster;* Handles of spice cabinet;* Radio mounted under spice cabinet;* Stand-up mixer;* Fans throughout the kitchen; and* Floor drains throughout the kitchen;b. The following equipment was in need of repair:* Trim and corner guards throughout the kitchen were lifted, broken or missing;* Ceiling tiles with holes throughout the kitchen;* Door and door frame to the dining room had gouged wood and chipped paint;* Sealant of previously repaired floor near drink station was worn and missing in some areas;* Dish racks were chipped and broken;* Temperature gauge covers of the warewasher machine were missing;* Cabinets under the steam table had exposed wood and multiple broken handles and misaligned doors;* Stand-up mixer coating was chipped;* Stainless steel three tiered cart had a broken handle;* Multiple cutting boards had brown marks and were warped; * Walk-in freezer door was rusted and had a broken seal which caused frozen condensation to line the exterior edges of the door; * Walk-in refrigerator door, walls and floors were rusting, including around the fire sprinkler system;* White upright refrigerator had a discolored and broken seal around the door;* Prep sink pipes were leaking;* Unpainted wood panel attached to the wall underneath the prep sink; and* Sink faucet in warewash area was broken and unable to be turned off. c. Staff lacked good infection control related to the use of aprons for caregivers serving food, hand hygiene during food preparation, hand hygiene between dirty and clean tasks, and use of gloves.The need to ensure the kitchen was clean, in good repair, and infection control processes were followed in accordance with the Food Sanitation Rules OAR 333-150-000 was discussed with Staff 2 (Dining Services Director), Staff 3 (Designee) and Staff 4 (Maintenance) on 02/22/24. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:On 06/27/24 at 1:00 pm, the facility's kitchen was toured and food service was observed. The following areas were in need of repair:* The conveyor toaster had a broken leg and was covered in food debris and grease build-up; * Steam table needing repair; * Walk-in freezer door was broken with frozen condensation lining the exterior edges of the door; and* Walk-in walls, doors, floors and ceiling including fire sprinkler system were rusting. At 1:15 pm in an interview with Staff 2 (Food Services Director), he stated he was getting bids to replace the steam table completely. The need to ensure the kitchen was clean and in good repair was discussed with Staff 1 (Administrator) and Staff 2 (Dining Services Director) on 06/27/24. They acknowledged the findings.

Based on observation and interview, 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 C 240 and Z 142.
Based on observation and interview, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to:Refer to C240 and Z142.

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 C240.
Based on observation and interview, 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 240.
Please refer to tag C 240 and tag C 455

Based on observation and interview, 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 C240.

The findings of the re-licensure survey conducted 12/05/22 through 12/07/22 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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the re-visit to the re-licensure survey of 12/07/22, conducted 05/23/23 through 05/25/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, 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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the second re-visit to the re-licensure survey of 12/07/22, conducted 04/15/24 through 04/17/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, 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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day


The findings of the third re-visit to the re-licensure survey of 12/07/22, conducted 09/16/24 through 09/19/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.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. Tag numbers beginning with the letter H refer to the Home and Community Based Services rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a dayA situation was identified where there was a failure of the facility to comply with the Departments rules that was likely to cause a resident serious harm. An Immediate Plan of Correction was requested in the following area:OAR 411-054-0300 (11-13): Call SystemThe facility put an Immediate Plan of Correction in place during the survey.



The findings of the fourth re-visit to the re-licensure survey of 12/07/22, conducted on 11/25/24, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation, interview, and record review, it was determined the licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. Findings include, but are not limited to:During the second revisit to the re-licensure survey of 12/07/22, conducted 04/15/24 through 04/17/24, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of repeat citations.Refer to the deficiencies identified in the report.

Based on observation, interview, and record review, it was determined the licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. This is a repeat citation. Findings include, but are not limited to:During the third revisit to the re-licensure survey of 12/07/22, conducted 09/16/24 through 09/19/24, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on severity of repeat citations.Refer to the deficiencies identified in the report.

Based on observation, interview and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, staff performance, resident outcomes and resident satisfaction. Findings included, but are not limited to:During the survey, conducted 04/15/24 through 04/17/24, quality improvement oversight to ensure adequate resident care, services, satisfaction, and staff performance was found to be ineffective.Refer to the deficiencies in the report.

Based on observation and interview, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, staff performance, resident outcomes and resident satisfaction. This is a repeat citation. Findings included, but are not limited to:During the survey, conducted 09/16/24 through 09/19/24, quality improvement oversight to ensure adequate resident care, services, satisfaction, and staff performance was found to be ineffective.Refer to the deficiencies in the report.

Based on interview and record view, it was determined the facility failed to promptly investigate injuries of unknown cause to rule out abuse/neglect, document all required areas of an investigation, and notify the local SPD office when abuse/neglect could not be ruled out for 1 of 1 sampled resident (#5) reviewed with injuries of unknown cause. Findings include, but are not limited to: Resident 5 moved into the memory care community in 07/2019 with diagnoses including Alzheimer's disease. Resident 5's current service plan identified s/he was "mostly unable to verbalize his/her needs." A review of the resident's record including charting notes, dated 01/28/24 through 04/09/24, identified the following:* A chart note dated 03/21/24 indicated the resident was found with "purple bruises on both arms and two [on] both side[s] of [his/her] chest and a bump on the right side of [his/her] head...[Staff 4 (Memory Care Director)] and [Staff 9 (Director of Facility Operations)] was notified." This incident represented an injury of unknown cause that required an immediate investigation. On 04/16/24 at 9:43 am, survey requested an investigation of the injuries. At 3:43 pm, Staff 9 reported there wasn't an investigation completed, nor had the facility reported to the local SPD office when abuse/neglect could not be ruled out.The need to investigate injuries of unknown cause to rule out suspected abuse and/or report to SPD if unable to reasonably rule out suspected abuse was discussed with Staff 3 (Health Services Director/RN), Staff 4 and Staff 9 on 04/16/24. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was clean and in good repair, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:On 12/05/22 at 9:40 am, the facility kitchen was observed. The following deficiencies were identified:* Main entryway walls, door and door frame to the kitchen were dirty, had chipped paint and moulding in need of repair or replacement; * Convection oven, gas range, stainless steel tables and cabinet interiors had surfaces with layers of debris and food splatter on them;* Caulking around the sink in the food preparation area had a black substance on its surface and was porous, deeming the surface non-cleanable;* Floor throughout the kitchen including the walk-in refrigerator had a black substance on it;* On 12/05/22 at 9:46 am, a surveyor observed Staff 21 (Dietary Cook) and Staff 27 (Dietary Dishwasher) preparing food without wearing proper hair restraints; and* In interview on 12/05/22 at 12:37 pm, Staff 20 (Dietary Manager) failed to produce a current Oregon Food Handlers Card when requested.The need to ensure the kitchen was clean and in good repair in accordance the Food Sanitation Rules OAR 333-150-000 was discussed with Staff 1 (Interim Administrator) and Staff 20 on 12/07/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide an activity program based on individual and group interests, physical, mental, and psychosocial needs, and opportunities for active participation in the community at large. Findings include, but are not limited to:There were no scheduled or unscheduled activities observed on the memory care community on 12/05/22 (10:00 am - 4:00 pm) , 12/06/22 (9:00 am - 3:00 pm), and 12/07/22 (9:00 am - 10:00 am). On those days residents were observed in their rooms, watching TV on the unit, or sitting in common areas. In an interview on 12/06/22, Staff 3 (RN Director of The Cottages) acknowledged the lack of organized group activities in the MCC.On 12/07/22 the need for an organized activity program was discussed with Staff 1 (Interim Administrator) and Staff 3. They acknowledged the findings. No further information was provided.

2. Resident 1 was admitted to the facility in 2019 with diagnoses including Chronic Obstructive Pulmonary Disorder, shortness of breath, and cardiovascular disease.A review of the resident's clinical record, and interviews with staff and Resident 1 identified the following:The service plan dated 06/29/22 and noted as reviewed on 10/05/22 had not been updated and/or lacked clear instructions to staff in the following areas:* Resident smoking status;* Use of manual wheelchair or powered wheelchair; and* Presence of pressure ulcer and pressure relief interventions.The need to ensure service plans were completed, updated, and were accessible to staff was discussed with Staff 1 (Interim Administrator) and Staff 2 (Corporate Director of Nursing) on 12/07/22. They acknowledged the findings.
3. Resident 6 was admitted to the facility in 04/2020 with diagnoses including vascular dementia, emphysema and hypertension.A review of the resident's clinical record and interviews with staff indicated the following deficiencies:a. The most recent service plan, dated 07/19/22 had not been updated quarterly; andb. The service was not reflective of current status and/or lacked clear instructions for staff in the following areas: * Fall interventions/precautions;* Denture status;* Activities plan; and* Elopement prevention. On 12/07/22 the need to ensure service plans were completed quarterly, were reflective of current resident status, and provided clear instruction for staff was discussed with Staff 1 (Interim Administrator) and Staff 3 (RN Director of The Cottages). They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure service plans were completed upon move-in, updated within 30 days of move-in and quarterly thereafter, were accessible to staff, reflective of the resident's current status, care needs and preferences, and provided clear instruction regarding the delivery of services for 3 of 6 sampled residents (#s 1, 3 and 6), whose service plans were reviewed. Findings include but, are not limited to: 1. Resident 3 was admitted to the facility in 10/2022 with diagnoses including atrial fibrillation, congestive heart failure and anxiety. A review of the resident's clinical record, and interviews with staff and Resident 3 identified the following:a. The initial service plan was not completed and a 30 day update had not been completed and made accessible to staff.b. The service plan review that had been completed was not reflective and/or lacked clear instructions to staff in the following areas:* Ability to use call light;* Medication management;* Behavior management including depression and interventions;* History of falls and fall interventions;* Assistance with daily weights;* Ability to eat independently;* Use of adaptive equipment (shower chair, toilet riser and hospital bed);* Preferred activities (watching football, basketball, pets and reading the daily newspaper); * Skin checks and monitoring for bed sores;* Use of home health PT services that were provided; * Reminders to lock brakes on walker prior to sitting;* Reminders to use incentive spirometer (manual machine for lung exercises); and* Encourage to walk halls BID, drink water and eat regularly.The need to ensure service plans were completed and updated within 30 days of move-in and provided clear instructions for staff was discussed with Staff 1 (Interim Administrator) and Staff 2 (Corporate Director of Nursing) on 12/07/22. They acknowledged the findings.
3. Resident 7 was admitted to the facility in 06/2016 with diagnoses including diabetes and fibromyalgia. Observation and interview with the resident, interviews with staff, and review of the current service plan during the survey, from 05/23/23 through 05/24/23, revealed Resident 7's service plan was not updated quarterly, was not reflective of the resident's status and lacked clear instructions in the following:* Use of bilateral half side rails;* Management of ongoing pain; and* Elderplace services.On 05/24/23 the service plan was discussed with Staff 9 (Facility Administrator). She acknowledged the service plans were not reflective of the resident's status and lacked clear instructions.
2. Resident 5 was admitted to the memory care community in 07/2019 with diagnoses including Alzheimer's Disease, atrial fibrillation and depression. On 05/23/23, the copy of Resident 5's quarterly service plan available for caregivers to review was dated 10/24/22. On 05/24/23, a copy of the service plan dated 05/05/23 was printed.A review of the resident's clinical record, and interviews with staff identified the following was missing or did not provide clear instructions for staff:* Side rail use;* Home Health and Hospice;* Pressure alarm and fall interventions; and* Use of a wheelchair and gait belt.The need to ensure service plans were updated quarterly and provided clear instructions to staff was discussed with Staff 1 (RCC) on 05/24/23 and Staff 9 (Facility Administrator) on 05/23/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were updated quarterly, were reflective of the resident's current status, care needs and preferences, and provided clear instruction regarding the delivery of services for 3 of 3 sampled residents (#s 5, 7 and 8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 8 was admitted to the facility in 12/2021 with diagnoses including chronic obstructive pulmonary disease, congestive heart failure and anxiety. A review of the resident's clinical record, and interviews with staff and Resident 8 identified the following:The service plan with most recent updates dated 10/27/22 was not updated quarterly, was not reflective and/or lacked clear instructions to staff in the following areas:* Use of modified utensils for eating;* Use and safety instructions for the transfer pole including placement of furniture to remain in the same location to ensure proper body mechanics when transferring;* Use of hospital bed and ensure resident elevating HOB/FOB;* Preference to sleep with head at foot of bed;* Use of bilateral 1/2 length side rails, risks, precautions and who was to monitor and how often to monitor the side rails functioning and the residents' ability to continue safely using the side rails;* Use of oxygen and nebulizer, including instructions related to infection control and monitoring oxygen saturation levels;* Application and cleaning instructions for compression socks/wraps; and* Current falls and fall interventions. The need to ensure service plans were updated quarterly and provided clear instructions to staff was discussed with Staff 1 (RCC) on 05/24/23 and Staff 9 (Facility Administrator) on 05/23/23. They acknowledged the findings.



Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of the resident's current status and care needs, provided clear instruction regarding the delivery of services and were implemented for 1 of 5 sampled residents (#5) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 5 moved into the memory care community in 07/2019 with diagnoses including Alzheimer's disease and depression. A review of the resident's clinical record, including a review of the service plan dated 01/24/24, temporary service plans, interviews with staff and observations of the resident's care was conducted during the survey. a. The following areas were not reflective of the resident's current status and care needs and did not provide clear instructions for staff:* The use of over-the-counter pain medications; * Ability to communicate symptoms of depression; and* History of weight loss and interventions.b. The following service-planned care needs were not implemented:* Toileting and brief changes every two hours;* Repositioning every two hours when in bed or geri-chair;* Safety checks every two hours when napping in bed; and* Daily one-on-one activities.The need to ensure service plans were reflective of the resident's current status and care needs, provided clear instruction regarding the delivery of services and were implemented was discussed with Staff 3 (Health Services Director/RN), Staff 4 (Memory Care Director) and Staff 9 (Director of Facility Operations) on 04/17/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that 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 2 sampled memory care residents (#s 5 and 6) whose service plans were reviewed. Findings include, but are not limited to:The most recent service plans for Residents 5 and 6 lacked documented evidence that a Service Planning Team reviewed and participated in the development of the service plans.On 12/07/22 the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Interim Administrator) and Staff 3 (RN Director of The Cottages). They acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to determine, document and communicate to staff what actions or interventions were needed for a resident following a change of condition, that interventions were resident-specific, interventions were monitored for effectiveness, and weekly progress noted until the condition resolved for 2 of 6 sampled residents (#s 2 and 5) who experienced short-term changes of condition. Findings include, but are not limited to:1. Resident 5 was admitted to the memory care community in 07/2019 with diagnoses including Alzheimer's Disease, atrial fibrillation and depression. In an acuity interview on 12/05/22, Staff 1 (Interim Administrator) identified Resident 5 was a "high fall risk."The resident's service plan, dated 10/24/22, progress notes, dated 09/05/22 through 12/05/22, temporary service plans, and incident reports were reviewed. The records indicated Resident 5 experienced the following four falls from 09/08/22 through 10/31/22: * 09/08/22- another resident pushed Resident 5, causing him/her to fall in hallway;* 09/21/22- Resident 5 slid on wet grass in courtyard and fell;* 10/09/22- the resident slid out of recliner and landed on floor; and * 10/31/22- Resident 5 tripped and fell in hallway.Temporary service plans were created for these falls, but lacked resident-specific interventions, evidence of new interventions being tried, or evaluation of those interventions for effectiveness.On 12/07/22 the need to implement resident-specific interventions following changes of condition, and to evaluate those interventions for effectiveness was discussed with Staff 1 and Staff 3 (RN Director of The Cottages). They acknowledged the findings.
2. Resident 2 was admitted to the facility in 2021 and was noted to experience urinary tract infections frequently.Review of the resident's TSPs (Temporary Service Plans), Incident Reports and progress notes dated 09/07/22 through 12/02/22, indicated the resident experienced the following short-term changes of condition:* 09/07/22 - Fall;* 09/12/22 - Fall;* 09/12/22 - Emergency room visit (for dehydration);* 09/13/22 - Fall;* 09/13/22 - Fall;* 09/14/22 - Fall;* 09/14/22 - Urinary tract infection;* 10/22/22 - Edema and pain to bilateral lower extremities; and* 11/29/22 - Fall.The facility lacked documented evidence it determined resident-specific interventions or actions, communicated the interventions or actions to staff on all shifts, and monitored the conditions with progress noted at least weekly through resolution for each of Resident 2's short-term changes of condition.Short-term changes of condition and monitoring was discussed with Staff 1 (Interim Administrator) and Staff 2 (Corporate Director of Nursing) on 12/07/22. They acknowledged the findings.
3. Resident 7 was admitted to the facility in 06/2016 with diagnoses including diabetes.The resident's progress notes dated 02/22/23 through 03/10/23, and temporary service plans were reviewed. The following short term change of condition was identified:* 03/01/23 - Change in medications.There was no documented evidence the facility determined what action or intervention was needed and communicated to staff on each shift. The need to ensure resident specific actions or interventions were determined and communicated to staff was discussed with Staff 9 (Facility Administrator) on 05/24/23. She acknowledged the findings.
2. Resident 5 was admitted to the memory care community in 07/2019 with diagnoses including Alzheimer's Disease, atrial fibrillation and depression. The resident's service plan, dated 05/05/23, progress notes dated 02/06/23 through 05/23/23, temporary service plans, and incident reports were reviewed. The records indicated Resident 5 experienced the following falls from 02/06/23 through 05/23/23: * 02/21/23 - fell out of wheelchair in dining room;* 02/22/23 - found on floor in room;* 02/26/23 - found on floor in room;* 03/13/23 - fell onto floor;* 03/14/23 - three falls in one day;* 03/17/23 - found on floor;* 03/20/23 - found on floor in room;* 03/23/23 - fell in room;* 04/01/23 - found on floor in room;* 04/03/23 - fell to floor;* 04/25/23 - fall in dining room;* 05/04/23 - fell in hallway;* 05/07/23 - found on floor;* 05/10/23 - fell in another resident room;* 05/17/23 - fell out of wheelchair;* 05/21/23 - fell in courtyard; and* 05/23/23 - found on floor.Temporary service plans were created for the falls, but lacked resident-specific interventions, evidence of new interventions being tried, or evaluation of those interventions for effectiveness.On 05/24/23 the need to develop and implement resident-specific interventions following changes of condition and to evaluate those interventions for effectiveness was reviewed with Staff 1 (RCC), Staff 35 (RN), and Staff 9 (Facility Administrator) on 05/24/23. They acknowledged the findings.


Based on interview and record review, it was determined the facility failed to determine, document and communicate to staff what actions or interventions were needed for a resident following a change of condition, ensure interventions were resident-specific, interventions were monitored for effectiveness, and weekly progress noted until the condition resolved for 3 of 3 sampled residents (#s 5, 7 and 8) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:1. Resident 8 was admitted to the facility in 12/2021 with diagnoses including chronic obstructive pulmonary disease, congestive heart failure and anxiety. Review of the resident's Temporary Service Plans (TSP's) and progress notes dated 02/23/23 through 05/23/23 were reviewed during the survey and identified the following changes in condition:* 02/23/23 - "missed inhaler medication. Inhaler was empty and no extra inhalers could be found. Inhaler on order";* 03/26/23 - missed pain medication (oxycodone);* 04/04/23 - fall with rib pain; * 05/08/23 - injury fall with left dislocated index finger;* 05/08/23 - "return to facility + new medications"; and* 05/16/23 - shortness of breath.There was no documentation the missed respiratory medication and pain medications were communicated to staff or there was no monitoring through resolution.There was no documented evidence the facility reviewed fall interventions for effectiveness and new interventions were implemented in order to mitigate the potential for future falls and there was no documented evidence the 05/08/23 fall was communicated to staff. There was a TSP for the 05/08/23 return to facility; however, the TSP lacked clear monitoring instructions related to additional care needs to include: "buddy taping" fingers. The TSP lacked clear monitoring instructions including the name of the new medications and for what the staff should monitor. There was no documented evidence monitoring instructions or interventions for the resident's shortness of breath and low oxygen saturation level were communicated to staff.The need to ensure the facility determined resident-specific interventions or actions, communicated the interventions or actions to staff on all shifts, and monitored the conditions with progress noted at least weekly through resolution was discussed with Staff 1 (RCC) and Staff 9 (Facility Administrator) on 05/23/23 and 05/24/25. They acknowledged the findings.




Based on interview and record review, it was determined the facility failed to determine, document and communicate to staff what actions or interventions were needed for a resident following a change of condition and ensure weekly progress noted until the condition resolved for 1 of 5 sampled residents (#5) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:Resident 5 moved into the memory care community in 07/2019 with diagnoses including Alzheimer's disease.A review of the resident's clinical record, including charting notes dated 01/28/24 through 04/09/24, temporary service plans for the same time period and interviews with staff was conducted during the survey. Resident 5 had the following changes of condition that lacked documentation of what action or intervention was needed, the determined action or intervention communicated to staff on each shift, and the condition monitored with weekly progress noted until the condition resolved:* 02/22/24 - 4 cm x 3 cm bruise to left upper arm;* 02/06/24 - Discoloration to buttock area;* 03/21/24 - Bruises on both arms and a bump on the right side of the head;* 03/24/24 - Pressure sore; and* 04/08/24 - Bruise to the back of the left hand.The need to ensure the facility determined and documented what action or intervention was needed for a resident following a change of condition, communicated the actions or interventions to staff and ensured weekly progress noted until the condition resolved was discussed with Staff 3 (Health Services Director/RN), Staff 4 (Memory Care Director) and Staff 9 (Director of Facility Operations) on 04/16/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a timely RN assessment was completed for 1 of 1 sampled resident (#5) who experienced a significant change of condition. Findings include, but are not limited to:Resident 5 was admitted to the memory care community in 07/2019 with diagnoses including Alzheimer's Disease, atrial fibrillation and depression.Progress notes between 02/06/23 and 05/23/23 were reviewed along with Resident 5's service plan, Temporary Service Plans (TSPs), physician orders and MAR. The following issues were identified:On 04/05/23 a progress note documented a meeting including two facility staff and Resident 5's daughter regarding:* Decline in ADL ability;* 15 falls in 90 days;* 4% unexplained weight loss in one month;* Increased sleep patterns;* Little to no verbal communication; and* Admission to hospice.The changes in ADL ability, frequent falls, unexplained weight loss, decreased communication, and admission to hospice constituted a significant change of condition.There was no documented RN assessment of Resident 5's change of condition with findings, resident status, and interventions made as a result of the assessment. The service plan was not updated until one month later, on 05/05/23.The need to ensure conditions that represent significant changes of condition are assessed timely by the facility RN was discussed with Staff 1 (RCC), Staff 35 (RN), and Staff 9 (Facility Administrator) on 05/24/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (#4) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:During the acuity interview on 12/05/22, Resident 4 was identified to be administered insulin injections by non-licensed staff.Delegation records for Staff 11, 12 and 22 (MTs), reviewed on 12/06/22 and 12/07/22, lacked documentation in the following areas:* An RN assessment of the resident's condition;* Rationale that the task could be safely delegated to the CG;* Rationale for how frequently the client should be reassessed by the RN; and* Rationale for how frequently the unlicensed person(s) should be supervised and reevaluated based on the competency of the MT.The need to ensure all staff who administered insulin injections were appropriately delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1 (Interim Administrator) and Staff 2 (Corporate Director of Nursing) on 12/07/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (#7) who received insulin injections by unlicensed facility staff. This is a repeat citation. Findings include, but are not limited to:During the acuity interview on 05/23/23, Resident 7 was identified to be administered insulin injections by non-licensed staff.Delegation records and staff interviews revealed the following:* Lack of an RN assessment of the resident's condition; * Only insulin preparation was delegated and not administration; and* Resident was self-administering the insulin with the assistance of the unlicensed staff.The need to ensure the resident was assessed by the RN, staff completed all the components of insulin administration and not just a portion and staff who administered insulin injections were appropriately delegated in accordance with OSBN Division 47 Rules was discussed with Staff 9 (Facility Administrator) on 05/24/23. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure delegation was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules for 1 of 1 sampled resident (#12) who received insulin injections by a unregulated assistive person (UAP). This is a repeat citation. Findings include, but are not limited to:According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the UAP, teaching the task, and observing the staff demonstrate the task.During the acuity interview on 04/15/24, Resident 12 was identified to be administered insulin injections by UAPs. Resident 12's MARs dated 03/01/24 through 04/14/24 and delegation records were reviewed with Staff 3 (Health Services Director/RN) on 04/16/24. a. An RN assessment of the resident's condition failed to document the following: * The frequency of resident assessment deemed necessary by the RN to determine the ongoing stability and predictability of the resident's responses to their condition; and* The resident's responses to other actual or potential health problems that may impact their responses to the condition for which the nursing procedure was ordered.b. The RN re-evaluation of the UAP failed to document the following:* The nursing procedure delegated;* Whether the RN had authorized the same UAP to perform the same nursing procedure previously;* The length of time the RN had worked with the UAP as a health care team member;* Evaluation of the UAP's documentation of performance of the nursing procedure;* Address questions or concerns the UAP and client may have; * Direct observation of the UAP in their performance of the nursing procedure on the client; and* Documentation of the length of the UAP's authorization period with data supporting the decision.The need to ensure the resident was assessed by the RN and the UAP was delegated in accordance with OSBN Division 47 Rules was discussed with Staff 3, Staff 4 (Memory Care Director) and Staff 9 (Director of Facility Operations) on 04/16/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to coordinate on-site health services with outside service providers, ensure staff were informed of new interventions, the service plan was updated and reporting protocols were in place for 1 of 2 sampled residents (#3) who was reviewed with outside service providers. Findings include but, are not limited to:Resident 3 was admitted to the facility in 10/2022 with diagnoses including atrial fibrillation and congestive heart failure. A review of the service plan, temporary care plans and outside provider notes reviewed during the survey identified the following recommendations were not communicated to staff, nor was the service plan updated and followed related to:* Behavior support plan and interventions;* Daily weights;* Encourage resident to get out of bed;* Encourage resident to walk halls BID;* Remind resident to use incentive spirometer TID (manual machine for lung exercises); and* Remind resident to lock brakes on walker prior to sitting down on it. During an interview on 12/06/22, Staff 11 (MT) reported the facility didn't take the resident's weight. The resident was only weighed when s/he moved in. During an interview on 12/06/22 at 1:45 pm, Staff 1 (Interim Administrator) confirmed the facility's process was to communicate the recommendations to staff on a temporary care plan. She acknowledged their were no temporary care plans for the above recommendations.

Based on interview and record review, it was determined the facility failed to ensure it had a trained Infection Control Specialist as required in OAR 411-054-0050 Infection Prevention and Control. Findings include, but are not limited to:In an interview on 12/06/22, Staff 1 (Interim Administrator) reported Staff 2 (Corporate Director of Nursing) was the facility's designated Infection Control Specialist. Review of Staff 2's infection control training revealed she had not completed the required specialized, Department-approved training in infection prevention and control protocols for an Assisted Living Facility Infection Control Specialist.The need to ensure the designated Infection Control Specialist completed all required training was reviewed with Staff 1 and Staff 2 on 12/07/22. They acknowledged training had not been completed as required.

2. Resident 2 was admitted to the facility in 2021 with diagnoses including diabetes. Review of 10/14/22 physician's orders, 11/01/22 through 12/05/22 MAR and 09/07/22 through 12/02/22 progress notes identified the following deficiency:According to the records, facility staff administered CBG testing to Resident 2 on the following dates:* 09/16/22;* 10/01/11;* 10/02/22;* 10/05/22;* 11/26/22; and* 11/30/22. The facility lacked a signed physician's order to administer CBG testing for Resident 2. The need to ensure written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments that the facility administered was discussed with Staff 1 (Interim Administrator) and Staff 2 (Corporate Director of Nursing) on 12/07/22. No further information was provided.
Based on interview and record review, it was determined the facility failed to ensure written, signed physician or other legally recognized practitioner orders were documented in the resident's record for all medications and treatments that the facility was responsible to administer and medication and treatment orders were carried out as prescribed for 2 of 6 sampled residents (#s 2 and 3) whose records were reviewed. Findings include but, are not limited to: 1. Resident 3 was admitted to the facility in 10/2022 with diagnoses of atrial fibrillation and congestive heart failure.A review of the 12/2022 MAR and current physician orders dated 10/17/22 identified the following: Resident 3 was prescribed furosemide, give one tablet as needed, for weight gain of three pounds overnight/five pounds in a week and potassium chloride as needed, for weight gain of three pounds overnight/five pounds in a week. During an interview on 12/06/22, Staff 11 (MT) reported the facility wasn't taking the resident's weight. The need to ensure the facility followed signed physician orders as prescribed was discussed with Staff 1 (Interim Administrator) and Staff 2 (Corporate Director of Nursing) on 12/07/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident-specific parameters for PRN medications for 4 of 6 sampled residents (#s 2, 3, 4 and 6) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in 10/2018 with diagnoses including diabetes and dementia.Resident 4's 12/01/22 through 12/05/22 MAR was reviewed and identified the following:* PRN oxycodone and PRN Tylenol for pain with no clear direction to staff regarding which to give first;* Lantus (for diabetes) without resident-specific parameters of when to hold;* Novolog (for diabetes) lacked clear parameters for low CBGs; and* Warfarin (anticoagulant) lacked reason for use.On 12/07/22, the need to ensure MARs were accurate was discussed with Staff 1 (Interim Administrator) and Staff 2 (Corporate Director of Nursing). They acknowledged the findings, and no further information was provided.
2. Resident 6 was admitted to the facility 04/2020 with diagnoses including vascular dementia, emphysema and hypertension.Review of Resident 6's MAR, dated 12/01/22 to 12/05/22, identified the following:*The MAR listed the following PRN bowel medications for constipation: Milk of Magnesia, senna, bisacodyl suppository and polyethylene glycol. The MAR lacked parameters for these medications, to direct the sequential order of use.*The MAR listed the following PRN medications for pain: acetaminophen, morphine sulfate and trolamine salicytate. The MAR lacked parameters for these medications, to direct the sequential order of use.On 12/07/22 the need to ensure an accurate MAR was kept of all medications ordered by a legally recognized prescribe and administered by the facility was discussed with Staff 1 (Interim Administrator) and Staff 3 (RN Director of The Cottages). They acknowledged the findings.
3. Resident 2 was admitted to the facility in 2021 with diagnoses including diabetes. The resident's 11/01/22 through 12/05/22 MAR and 11/07/22 through 12/05/22 Medication Administration History records were reviewed and revealed the following:* An order for sucralfate one gram tablet (stomach pain), take one gram to two grams by mouth twice daily, lacked resident-specific parameters and instructions for staff on when to give one tablet versus two tablets, or if the resident could self-direct the medication; and* On multiple occasions, the facility failed to record the dosage of sucralfate administered to Resident 2.The need to ensure MARs were accurate, and included dosage and resident-specific parameters and instructions, was discussed with Staff 1 (Interim Administrator) and Staff 2 (Corporate Director of Nursing) on 12/07/22. They acknowledged the findings.
4. Resident 3 was admitted to the facility in 10/2022 with diagnoses including atrial fibrillation and congestive heart failure. A review of the 12/2022 MAR identified the following inaccuracies:* On four occasions the 12/2022 MAR lacked initials of the person who administered simethicone (antacid chewable);* Polyethylene glycol and sennosides, as needed (both for bowel care), lacked resident specific parameters including instructions of which medication to administer first; and* Atorvastatin calcium, finasteride, simethicone and Ambien lacked reason for use. The need to ensure MARs were accurate and included initials of the person who administered the medications, parameters for multiple PRN medications used to treat the same condition, and had reason for use for all medications was discussed with Staff 1 (Interim Administrator) and Staff 2 (Corporate Director of Nursing) on 12/07/22. They acknowledged the findings.
3. Resident 7 was admitted to the facility in 06/15/23 with diagnoses including diabetes and fibromyalgia.Resident 7's 05/01/23 through 05/23/23 MAR was reviewed and identified the following:* PRN Tylenol (for pain) and PRN oxycodone (for pain) lacked resident-specific parameters for which to use first.* Staff initialed on the MAR they administered insulin, however, the resident administered it.On 05/24/23, the need to ensure MARs had clear parameters for unlicensed staff to follow and staff were not initialing for medications they did not administer was discussed with Staff 9 (Facility Administer). She acknowledged the findings.


Based on observation, interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident-specific parameters for PRN medications for 2 of 3 sampled residents (#s 7 and 8) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 8 was admitted to the facility in 12/2021 with diagnoses including chronic obstructive pulmonary disease, congestive heart failure and anxiety. A review of the 05/01/23 through 05/23/23 MAR and current physician orders dated 04/05/23 identified the following deficiencies:* An order for Zofran (for nausea) every 6 hours, as needed was not transcribed onto the MAR.* A physician order instructed staff to administer 4 to 6 LPM (liters per minute) by nasal cannula for comfort to maintain saturation between 92% and 95%. The MAR indicated to administer the oxygen as needed, staff were not initialing the MAR for oxygen administration and staff failed to document oxygen saturation levels. * The MAR lacked parameters for PRN milk of magnesia and PRN polyethylene glycol powder, both used to treat constipation. * The MAR was initialed by unlicensed staff indicating staff applied tubi-grip socks on the residents lower extremities on 05/23/23 and 05/24/23. During observations on both days the resident was not wearing tubi-grip socks. There was no documented evidence on the MAR that the resident had refused the treatment. The need to ensure MARs included all prescribed medications transcribed accurately on the MAR, treatment refusals were accurately documented on the MAR and parameters for multiple PRN medications used to treat the same condition were discussed with Staff 1 (RCC) and Staff 9 (Facility Administrator). They acknowledged the findings.

2. Resident 5 was admitted to the memory care community in 07/2019 with diagnoses including Alzheimer's Disease, atrial fibrillation and depression. Review of Resident 5's clinical record indicated the following:The 05/01/23 through 05/23/23 MAR, indicated staff administered the PRN psychotropic medications:* Diazepam 5 mg 12 times;* Lorazepam 0.5 mg 1 time; and* Quetiapine 25 mg 1 time. There was no documented evidence the staff attempted and documented non-drug interventions with ineffective results prior to administering the medication.The need to ensure non-pharmacological interventions were attempted and, documented with ineffective results prior to administering the medications was reviewed with Staff 1 (RCC), Staff 35 (RN), and Staff 9 (Facility Administrator) on 05/24/23. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure medication specific instructions were included on the MAR and non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications, for 2 of 2 sampled residents (#s 5 and 8) who were prescribed PRN psychotropic medications. Findings include, but are not limited to:1. Resident 8 was admitted to the facility in 12/2021 with diagnoses including chronic obstructive pulmonary disease, congestive heart failure and anxiety.Review of Resident 8's clinical record indicated the following:* Resident 8 was prescribed hydroxyzine 50 mg capsule, as needed, three times daily (to treat anxiety);* The 05/01/23 through 05/23/23 MAR lacked clear medication specific instructions regarding how long to wait before administering the next dose; and* The 05/01/23 through 05/23/23 MAR, indicated staff administered 21 doses of PRN hydroxyzine. There was no documented evidence the staff attempted and documented non-drug interventions with ineffective results prior to administering the medication.The need to ensure medication specific instructions and non-pharmacological interventions were attempted and, documented with ineffective results prior to administering the medications was reviewed with Staff 1 (RCC) and Staff 9 (Facility Administrator) on 05/24/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure non-pharmacological interventions had been tried and documented with ineffective results prior to administering PRN psychotropic medications for 1 of 1 sampled resident (#5) who was prescribed a PRN psychotropic medications. This is a repeat citation. Findings include, but are not limited to:Resident 5 moved into the memory care community in 07/2019 with diagnoses including Alzheimer's disease and depression. Review of MARs dated 03/01/24 through 04/15/24 and charting notes for the same time period identified the following:Resident 5 was prescribed diazepam 5 mg every four hours PRN for anxiety, andunlicensed staff administered the PRN psychotropic medication on 03/29/24, 04/06/24 and 04/10/24.There was no documented evidence non-pharmacological interventions had been tried with ineffective results prior to administering the medication.The need to ensure non-pharmacological interventions were attempted and documented with ineffective results prior to administering the medications was reviewed with Staff 3 (Health Services Director/RN), Staff 4 (Memory Care Director) and Staff 9 (Director of Facility Operations) on 04/16/24. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure a resident who utilized a supportive device with potentially restraining qualities was informed of the risks and benefits of the device, there was documentation of less restrictive alternatives prior to use, instruction to caregivers on the correct use and precautions related to the device, and the use of the device was included in the service plan for 1 of 3 sampled residents (#2) who had bi-lateral quarter-length side rails on their bed. Findings include, but are not limited toResident 2 was admitted to the facility in 2021 with diagnoses including arthritis. On 12/05/22 at 11:45 am, the resident was observed to have bi-lateral quarter length side rails on his/her bed.On 12/05/22, review of the "Supportive Device With Restraining Characteristics Assessment and Review" form dated 09/30/22 lacked documented evidence of the following:* Other less restrictive alternatives were evaluated prior to the use of the device;* Resident 2 was informed of risks and benefits associated with use of the device; * Caregivers were instructed on the correct use and precautions related to the device; and * The use of the device was included in the resident's service plan.Requirements regarding the use of devices with potentially restraining qualities were discussed with Staff 1 (Interim Administrator) and Staff 2 (Corporate Director of Nursing) on 12/07/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to select and implement an Acuity-Based Staffing Tool (ABST), complete an ABST assessment for each resident, and develop the facility's staffing plan based on the ABST. Findings include, but are not limited to:In an interview on 12/07/22, Staff 1 (Interim Administrator) stated the facility had not implemented an ABST to use in developing the facility staffing plan.On 12/07/22, the requirement to complete an assessment of each resident and implement an ABST was discussed with Staff 1. She acknowledged the lack of an ABST.

Based on interview and record review, it was determined the facility failed to fully implement an Acuity-Based Staffing Tool (ABST), complete an ABST assessment for each resident, and develop the facility's staffing plan based on the ABST. This is a repeat citation. Findings include, but are not limited to:In an interview on 05/23/23, Staff 9 (Facility Administrator) stated the facility had not yet assessed each resident and entered the assessment information into the ABST. As a result, the ABST was not generating information regarding the staffing levels needed which could be used to develop a facility staffing plan.On 05/23/23, the requirement to complete an assessment of each resident and implement an ABST was discussed with Staff 9. She acknowledged the lack of an ABST.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired direct care staff (#s 29, 30 and 8) completed First Aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to:Staff training records were reviewed on 12/06/22. The following deficiencies were identified:Staff 29 (CG) was hired 08/16/22, Staff 30 (MT) was hired 09/16/22 and Staff 8 (CG) was hired 09/24/22. There was no documented evidence Staff 29, 30 and 8 completed First Aid and abdominal thrust training within 30 days of hire.The need to ensure staff completed all required training as specified in the rules was reviewed with Staff 1 (Interim Administrator) and Staff 2 (Corporate Director of Nursing) on 12/07/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure 1 of 1 sampled newly-hired direct care staff (#33) completed First Aid and abdominal thrust training within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:Staff training records were reviewed on 05/24/23. The following deficiencies were identified:Staff 33 (MT) was hired 01/24/23. There was no documented evidence Staff 33 completed First Aid and abdominal thrust training within 30 days of hire.The need to ensure newly-hired direct care staff completed all required training as specified in the rules was reviewed with Staff 9 (Facility Administrator). She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to conduct fire drills according to the Oregon Fire Code (OFC), ensure alternate exit routes are used during fire drills, ensure staff know the designated point of safety outside the building and provide fire and life safety training to staff on alternate months. Findings include, but are not limited to:Fire drill and Fire and Life Safety training records for the six months prior to the survey were requested and reviewed on 12/06/22. The following deficiencies were identified:1. The facility was not conducting fire drills every other month. The only fire drills documented within the last six months were conducted on 10/26/22 and 10/27/22.a. The fire drill records lacked the following documentation:* Time of day (the record did not indicate "am" or "pm");* The escape route used;* Problems encountered, comments relating to residents who resisted or failed to participate in the drills;* Number of occupants evacuated; and* There was no evidence alternate exit routes were used during fire drills to react to varying potential fire origin points.b. In interviews on 12/06/22, Staff 8 (CG) and Staff 19 (MT) stated they did not know and had not been trained on the designated point of safety outside the building.2. In an interview on 12/06/22, Staff 1 (Interim Administrator) stated staff completed one online Fire and Life Safety course annually. The facility did not provide fire and life safety instruction to staff on alternate months as required in the rule.The need to ensure fire drills and fire and life safety training for staff were provided per the rule was reviewed with Staff 1 on 12/07/22 at 1:40 pm. She acknowledged the findings. The surveyor provided her a copy of OAR 411-054-0090.

Based on interview and record review, it was determined the facility failed to conduct fire drills according to the Oregon Fire Code (OFC), ensure alternate exit routes were used during fire drills, ensure staff know the designated point of safety outside the building and provide fire and life safety training to staff on alternate months. This is a repeat citation. Findings include, but not limited to:Fire drill and Fire and Life Safety training records for the six months prior to the revisit survey were requested and reviewed on 05/23/23. The following deficiencies were identified:1. In an interview on 05/23/23, Staff 9 (Facility Administrator) stated the facility did not conduct fire drills every other month. The only fire drills documented within the last six months were actual fire alarm events. Review of the fire event documentation indicated the "Fire Emergency Drill Checklist" form the facility used for fire drills lacked space to document the following required information:* The escape route used; and* Problems encountered, comments related to residents who resisted or failed to participate in the drills.2. In an interview on 05/23/23 Staff 9 (Facility Administrator) stated the facility was providing staff fire and life safety training upon hire and once annually. The facility did not provide fire and life safety instruction to staff on alternate months as required in the rule.The need to ensure fire drills and fire and life safety training for staff were provided per the rule was reviewed with Staff 9, Staff 32 (Regional Maintenance Director) and Staff 23 (Maintenance) on 05/24/23 at 12:50 pm. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to conduct and record fire drills according to the Oregon Fire Code (OFC) every other month and provide fire and life safety instruction to staff on alternate months. This is a repeat citation. Findings include, but are not limited to:On 04/16/24, this surveyor requested fire drill and fire and life safety training records from Staff 9 (Director of Facility Operations). She stated she did not know where the records were, the employee who kept those records had been on leave, and she would attempt to get in touch with that employee to locate the records. On 04/17/24, Staff 9 reported she had still been unable to locate the records. Review of the facility's "2024 Inservice Calendar" indicated fire and life safety training for employees was only scheduled twice during the year, not every other month as required in the rule. The facility failed to provide documentation it was conducting fire drills every other month per the OFC and providing fire and life safety training to staff on alternate months.The need to ensure fire drills and fire and life safety training was provided and documented was reviewed with Staff 9 and Staff 3 (Director of Health Services/RN) on 04/17/24. They acknowledged the lack of records.

Based on interview and record review, it was determined the facility failed to have a system for instructing residents within 24 hours of admission and re-instructing them, at least annually, on fire and life safety procedures. Findings include, but are not limited to:On 12/06/22, Staff 1 (Interim Administrator) was asked to explain the facility's process for providing residents with instruction on fire and life safety procedures upon admission and annually. Staff 1 reported a new resident was given a copy of the Resident Handbook which contained information about the facility's fire and safety drills. She acknowledged the facility had not been providing annual re-instruction on fire and life safety procedures to residents. Review of the Resident Handbook indicated "Office personnel will explain fire and life safety drill procedures to you."On 12/07/22, Staff 4 (Assistant to the Administrator) reported a new resident was given a copy of the Resident Handbook but acknowledged the resident was not provided any further instruction from the facility. She also confirmed that the facility was not providing annual re-instruction. The need to ensure residents received fire and life safety training within 24 hours of admission and annually was discussed with Staff 1 on 12/07/22. She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to have a system for instructing residents within 24 hours of admission and re-instructing them, at least annually, on fire and life safety procedures. This is a repeat citation. Findings include, but are not limited to:On 05/23/23 at 2:45 am, Staff 9 (Facility Administrator) was asked to explain the facility's process for providing residents with instruction on fire and life safety procedures upon admission and annually. Staff 9 stated a new resident was given a copy of the Resident Handbook which contained information about the facility's fire and safety drills. Staff 9 acknowledged the resident was not provided any further instruction. Staff 9 also stated the facility did not provide annual re-instruction. The need to ensure residents received fire and life safety training within 24 hours of admission and annually was discussed with Staff 9, Staff 32 (Regional Maintenance Director) and Staff 23 (Maintenance) on 05/24/23 at 12:50 pm. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have a system for instructing residents within 24 hours of admission and re-instructing them, at least annually, on fire and life safety procedures, and kept a written record of fire safety training including the content and residents attending. This is a repeat citation. Findings include, but are not limited to:On 04/17/24 at 11:20 am, this surveyor asked Staff 9 (Director of Facility Operations) about the facility's process for instructing new residents on fire and safety procedures following admission and reinstructing them annually. Staff 9 stated she was unsure as to whether the facility had developed a new process to meet the rule. Multiple sampled residents' service plans included the following statement: "Fire evacuation procedures have been reviewed with [resident]." However, Staff 9 stated she intended to implement a process that included the resident's acknowledgment of that training and their signature to ensure the instruction was provided.The need to ensure the facility had a system for instructing residents within 24 hours of admission and re-instructing them, at least annually, on fire and life safety procedures was reviewed with Staff 9 and Staff 3 (Director of Health Services/RN) on 04/17/24. They acknowledged the findings.

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 C260, C270, C282, C310, C 330, C361, C372, C420, C422, C610, C613, C615, C645, C655, Z155 and Z164.

Based on observation, interview and record review, it was determined the facility failed to submit a plan of correction that satisfied the Department. This is a repeat citation. Findings include, but are not limited to:Refer to C 260, C 270, C 282, C 330, C 420, C 422, C 455, C 610, C 613, C 615, and C 655.


Based on interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include but are not limited to:Refer to C 150, C 156, C 610, and C 655.It was determined the facility failed to submit a plan of correction that satisfied the Department.1. The facility has hired a consultant to assist in developing the plan of correction for each citation. 2. The administrator and consultant will work together to develop an acceptable plan of correction for each citation. 3. All areas of the plan of correction will be reviewed by the consultant prior to submission, this will occur at any time a plan is required for submission. 4. Administrator and Consultant are responsible to see that the plan of correction meets acceptable standards

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses were maintained in good repair and all chemicals were secure. Findings include, but are not limited to:The exterior areas of the facility were toured on 12/05/22 at 1:00 pm. The following were identified:1a. In the MCC courtyard, there were drop-offs of up to two inches, measured from the concrete to the planting bed surface. These areas created potential hazards for residents.b. In the ALF patio, there were drop-offs of up to two inches along the sidewalks surrounding the rose beds and around five 12" by 12" square areas near multiple arbor support posts. These areas created potential hazards for residents.2. The interior areas of the MCC were toured on 12/05/22 at 11:00 am. The following deficiencies were identified:a. Utility closets in both MCC units were unlocked and contained toxic chemicals. This presented potential risks to residents who resided on the units.b. MCC unit resident room 119's lockable medicine cabinet was unlocked. It contained the resident's inhaler and a bottle of mouthwash which contained alcohol. These items presented potential risks to that resident. In an interview on 12/05/22 at 12:10 pm, Staff 15 (MT) acknowledged she was unaware of the items left unsecured in the resident's medicine cabinet and stated she was sure the inhaler should not have been stored there; she was unsure of the facility's policy regarding MCC residents' access to mouthwash or other potentially dangerous chemicals. Staff 15 removed the resident's inhaler from the room.The exterior areas were toured with Staff 1 (Interim Administrator) and Staff 23 (Maintenance) on 12/05/22 at 2:55 pm. They acknowledged the drop-offs. The interior of the MCC was also toured and the need to ensure chemicals were secure was discussed. They acknowledged chemicals needed to be stored securely.
Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses were maintained in good repair and all chemicals were secured. This is a repeat citation. Findings include, but not limited to:The exterior areas of the facility were toured on 05/23/23 at 11:00 am. The following were identified:1a. In the MCC courtyard, there were drop-offs of up to two inches, measured from the concrete to the planting bed surface. These areas created potential hazards for residents. b. In the ALF patio, there were drop-offs of up to two inches along the sidewalks surrounding the rose beds and around five 12" by 12" square areas near multiple arbor support posts. There were also drop-offs along the pathways leading from the rear exit (near the raised planter boxes). These areas created potential hazards for residents.2. The interior areas of the MCC were toured on 05/23/23 at 10:45 am. A utility closet on the South MCC unit was unlocked and contained toxic chemicals. This presented potential risks to the residents who resided on the south unit.On 05/24/23 at 12:50 pm Staff 9 (Facility Administrator), Staff 32 (Regional Maintenance Director) and Staff 23 (Maintenance) declined a tour of the exterior areas and the interior of the South MCC unit. They acknowledged the drop-offs and the need to ensure chemicals were stored securely.

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses were maintained in good repair and there was locked storage for all chemicals. This is a repeat citation. Findings include, but not limited to:The exterior areas of the facility were toured at 9:06 am on 04/15/24. The following was identified:1a. In the MCC courtyard, there were drop-offs of up to two inches, measured from the concrete to the planting bed surface. These areas created potential hazards for residents. 1b. In the ALF patio, there were drop-offs of up to three inches along the sidewalks surrounding the rose beds and around five 12" by 12" square areas near multiple arbor support posts. There were also drop-offs along the pathways leading from the rear exit (near the raised planter boxes). These areas created potential hazards for residents.2a. The interior areas of the MCC were toured at 9:34 am on 04/15/24. Toxic chemicals were observed in unlocked storage in the following areas:* The housekeeping closet on the North MCC unit; and* The cabinets above the stove in the kitchenette on the North MCC unit.This presented potential risks to the residents who resided on the North MCC unit.2b. The interior areas of the ALF were toured at 9:46 am on 04/15/24. Toxic chemicals were observed in unlocked storage in the following areas:* On the counter by the sink in the public bathrooms on the 2nd and 3rd floors;* On a storage bin to the left of the door to Room 319; and* In the housekeeping closet on the 2nd floor.These unlocked chemicals presented potential risks to the resident who resided in the ALF.The need to ensure all exterior pathways and accesses were maintained in good repair and there was locked storage for all chemicals was discussed with Staff 9 (Director of Facility Operations) on 04/16/24. She acknowledged the findings.


Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were maintained in good repair. This is a repeat citation. Findings include, but are not limited to:On 09/17/24 and 09/18/24 the exterior of the facility was toured. The following was identified:a. The Memory Care (MC) courtyard had drop-offs that were measured up to three and a half inches located along the paved pathway and near to resident planter boxes. These areas created potential hazards for residents.b. The Assisted Living (AL) courtyard had drop-offs measured up to four and a half inches along the paved pathways located around the perimeter of the resident planter boxes, an AL facility exit door near the resident's planter boxes, and near the wooden benches throughout the courtyard. These areas created potential hazards for residents.On 09/18/24 at 9:47 am, the MC and AL courtyards were toured with Staff 23 (Maintenance). He confirmed he was aware of the drop offs.The need to ensure all exterior pathways were maintained in good repair was discussed with Staff 2 (Corporate Director of Nursing/ Administrator), Staff 23, Staff 37 (Corporate Director of Wellness), Staff 38 (Resident Services Director), Staff 39 (Director of the Cottages), and Staff 40 (LPN) on 09/18/24. They acknowledged the findings.It was determined the facility failed to ensure all exterior pathways and accesses were maintained in good repair 1. Contracts are in place for exterior maintenance and repairs for drop offs and uneven surfaces. 2. Administrator and Maintenance Director will have scheduled quarterly walk through inspections of the building exterior to ensure pathways are safe 3. Administrator or designee will perform random audits, at least 2x/month to ensure pathway drop offs are an acceptable height. 4. Administrator is responsible to see that the plan of correction meets acceptable standards.

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to:The interior of the facility was toured on 12/05/22 at 11:00 am. The following areas needed cleaning or repair:* Black recliner chair in the rear living room of MCC had spillage in cup holder;* Wall vents in common area next to Resident room 132 had dust build-up;* Ceiling light in the living area of MCC next to dining area had no cover and had a broken light fixture;* Resident room 120's bathroom door had a hole in the middle, paint on toilet seat was worn exposing bare wood, brown debris was noted on the shower floor;* Resident room 119's bathroom sink had a large chip, paint on toilet seat was worn exposing bare wood;* Several wooden patio benches outside the main dining area and in the MCC courtyard were worn and rough to the touch;* Three white round tables in the coffee area next to main dining area were noted to have damaged laminate, and the counter backsplash was warped and the laminate was coming off;* Folding counters in the resident laundry rooms on the 1st, 2nd and 3rd floors had damaged laminate;* Resident laundry room on the 2nd floor sink cabinet was missing right door, the rubber baseboard was peeling away from the wall; and * Resident room 205 had pervasive urine odor in the room.The building was toured and areas needing cleaning or repair were discussed with Staff 1 (Interim Administrator) and Staff 23 (Maintenance) on 12/05/22. They acknowledged the areas needing cleaning and repair.
Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. This is a repeat citation. Findings include, but are not limited to:The interior and exterior of the facility was toured on 05/23/23 at 9:40 am. The following areas needed cleaning or repair:Memory Care Community:* Resident room 119's bathroom sink had a large chip and paint on the toilet seat was worn exposing bare wood;* Resident room 120's bathroom door had a hole in the middle and paint on the toilet seat was worn exposing bare wood;* Resident room 137 was missing a door to the bathroom base cabinet; * The handrails at the entry to the north MCC unit were gouged and had chipped paint; and* Several wooden patio benches in the MCC courtyard were worn and rough to the touch;Assisted Living:* Three white round tables in the coffee area next to main dining area were noted to have damaged laminate, and the counter backsplash was warped and the laminate was coming off;* Handrails across from the 1st floor lobby elevator and across from the mailboxes were gouged and had chipped paint;* Folding counters in the resident laundry rooms on the 1st, 2nd and 3rd floors had damaged laminate;* Resident laundry room on the 2nd floor sink cabinet was missing a right door, the rubber baseboard was peeling away from the wall; * Resident room 333 had pervasive urine odor in the room; and* Several wooden patio benches in the ALF courtyard around the large statue were worn and rough to the touch.Assisted Living kitchen:* The entry area, including walls, door and frame, had multiple areas that were dirty or where paint was chipped, exposing bare wood that was an uncleanable surface;* Two lower open shelving areas under the steam table were missing laminate, exposing bare wood that was an uncleanable surface: and* Caulking around the three-compartment sink in the food preparation area had a black substance on its surface.The areas needing cleaning or repair were discussed with Staff 9 (Facility Administrator), Staff 32 (Regional Maintenance Director) and Staff 23 (Maintenance) on 05/24/23. They declined the surveyor's offer to tour the areas. They acknowledged the areas needing cleaning and repair.



Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair and free from unpleasant odors. This is a repeat citation. Findings include, but are not limited to:The interior and exterior of the facility was toured at 9:06 am on 04/15/24. The following areas needed cleaning or repair:A. Memory Care Community:* The heating vents and returns throughout the North and South MCC units had a buildup of dust and dirt;* Resident room 119's bathroom sink had a large chip, and paint on the toilet seat was worn exposing bare wood;* Resident room 120's bathroom door had a hole in the middle, and paint on the toilet seat was worn exposing bare wood;* The handrails at the entry to the north MCC unit were gouged and had chipped paint; and* Several wooden patio benches in the MCC courtyard were worn and rough to the touch.B. Assisted Living:* The heating vents and returns throughout the facility had a buildup of dust and dirt;* Three white round tables in the coffee area next to main dining area were noted to have damaged laminate, and the counter backsplash was warped and the laminate was coming off;* The handrails across from the 1st floor lobby elevator and across from the mailboxes were gouged and had chipped paint;* The folding counters in the resident laundry rooms on the 1st, 2nd, and 3rd floors had damaged laminate rendering the surfaces uncleanable; * The sink cabinet in the resident laundry room on the 2nd floor was missing a right door; * Resident rooms 206 and 330 had a pervasive urine odor; and* Several wooden patio benches in the ALF courtyard around the large statue were worn and rough to the touch.The areas needing cleaning or repair were discussed with Staff 9 (Director of Facility Operations) on 04/16/24. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure a lockable storage space was provided in each resident unit, and operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. Findings include, but are not limited to:1. During a group interview conducted by the survey team on 12/06/22 at 11:00 am, several residents reported they did not have a key to their lockable storage. Also, in an interview on 12/05/22, Resident 2 reported s/he did not have a key to the lockable storage in his/her unit.Unsampled resident rooms 233 and 226 were inspected on 12/07/22 between 10:45 am and 11:00 am. Each room had a medicine cabinet in the bathroom that had a locking device. Both residents stated, however, they did not have a key to lock the storage space.In an interview on 12/07/22, Staff 4 (Assistant to the Administrator) explained she was responsible for orienting new residents to the facility. She acknowledged she had not been giving new residents a key for their lockable storage, and stated existing residents may not have been given keys or lost their key.2. The windows of four randomly-sampled rooms were inspected on 12/06/22. Each resident unit included two vertically-opening windows with sill heights less than 36 inches. Three of the four units' windows had no device which limited how much the windows could open to prevent accidental falls. The fourth unit had one window that had a small limiting device but it was not secure and did not prevent the window from being opened fully.The need to ensure all residents had a key to the lockable storage space in their unit, and that all operable windows above the first floor were designed to prevent accidental falls was discussed with Staff 1 (Interim Administrator) on 12/07/22. She acknowledged the findings. Staff 1 reported she had staff inventory every resident that morning, and all residents would be provided a key to their storage space by the end of the day.

Based on observation and interview, it was determined the facility failed to ensure a lockable storage space was provided in each resident unit, and operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. This is a repeat citation. Findings include, but are not limited to:1. Unsampled resident rooms 205, 233, 313 and 333 were inspected on 05/23/23 and 05/24/23. Each room had a medicine cabinet in the bathroom that had a locking device. Only one resident in room 313 stated they had a key to lock the storage space.2. The windows of four randomly sampled rooms (205, 311, 313, and 333) were inspected on 05/23/23 and 05/24/23. Each resident unit included two vertically opening windows with sill heights less than 36 inches. None of the four units' windows had a device which limited how much the windows could open to prevent accidental falls.The need to ensure all residents had keys to their locked storage space and windows above the first floor had devices to prevent accidental falls was reviewed on 05/24/23 at 12:50 pm with Staff 9 (Facility Administrator), Staff 32 (Regional Maintenance Director) and Staff 23 (Maintenance). They acknowledged the findings.


Based on observation and interview, it was determined the facility failed to ensure a lockable storage space was provided in each resident unit, and operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. This is a repeat citation. Findings include, but are not limited to:1. Sampled and unsampled resident rooms 206, 209, 317, and 330 were inspected on 04/15/24. Each room had a medicine cabinet in the bathroom that had a locking device. All residents stated they did not have a key to the locking device when interviewed.2. The windows of four randomly sampled rooms (207, 217, 330, and 340) were inspected on 04/15/24 and 04/16/24. Each resident unit included two vertically opening windows with sill heights less than 36 inches. None of the four units' windows had a device which limited how much the windows could open to prevent accidental falls.The need to ensure all residents had keys to their locked storage space and windows above the first floor had devices to prevent accidental falls was reviewed on 04/16/24 with Staff 9 (Director of Facility Operations). She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure hot water temperatures in residents' units were maintained within a range of 110 to 120 degrees Fahrenheit (F). Findings include, but are not limited to:On 12/05/22, the surveyor measured water temperatures in occupied resident unit bathrooms and common area bathrooms throughout the assisted living and memory care units. The following were identified: * Resident room 131 (MCC) bathroom sink water temperature was 106.0 degrees F; and* Resident room 132 (MCC) bathroom sink water temperature was 88.4 degrees F.On 12/05/22, the water temperatures were discussed with Staff 1 (Interim Administrator) and Staff 23 (Maintenance). They both acknowledged the findings and Staff 23 stated that he did not have a process for monitoring water temperatures regularly.
Based on observation and interview, it was determined the facility failed to ensure hot water temperatures in residents' units were maintained within a range of 110-120 degrees Fahrenheit (F). This is a repeat citation. Findings include, but not limited to:On 05/23/23 and 05/24/23, the surveyor measured water temperatures in occupied resident unit bathrooms throughout the assisted living and memory care units. The following were identified: Memory Care Community:* Resident room 132 water temperature was 94.3 F; and* Resident room 137 water temperature was 102.4 F.Assisted Living:* Resident room 105 water temperature was 109.2 F;* Resident room 237 water temperature was 122.0 F;* Laundry room sink second floor water temperature was 124.7 F; and* Resident room 333 water temperature was 125.1 F.On 05/24/23 at 12:50 pm the water temperatures were discussed with Staff 9 (Facility Administrator), Staff 32 (Regional Maintenance Director) and Staff 23 (Maintenance). They acknowledged the findings. Staff 32 acknowledged they didn't have a system for monitoring water temps regularly. Staff 23 stated he monitored water temps daily at the boilers but not at the residents' sinks.

Based on observation and interview, it was determined the facility failed to ensure it provided a call system that connected resident units to the care staff, that a manually-operated emergency call system was provided at each resident bathroom and public-use restroom and exit door alarms or other acceptable system were provided for security purposes and to alert staff when residents exit the ALF. Findings include, but are not limited to:1. During a group interview conducted by the survey team on 12/06/22 at 11:00 am, several residents reported their personal call pendants did not work.Unsampled resident rooms 208, 223, 233 and 313 were inspected on 12/06/22 between 1:55 pm and 2:15 pm. The only system for connecting the resident unit to the care staff was by means of a wireless call pendant that each resident was provided.The resident in room 223 stated his/her call pendant did not work and the resident in room 233 stated s/he did not have a call pendant.2a. Resident rooms 208, 233 and 313 did not have a manually-operated emergency call system in the unit bathrooms. Room 223 had a wireless emergency call device in the bathroom but the resident stated it did not work.b. Public restrooms on the 1st and 2nd floors had wireless emergency call devices, not manually-operated devices as required in the rule.3. The facility was toured on 12/05/22 at 11:00 am. A door alarm in one of the MCC units and several door alarms in the ALF did not operate when the door was opened.The need to provide a call system that connected resident units to the care staff and a manually-operated emergency call system at each resident bathroom and public-use restroom was discussed with Staff 1 (Interim Administrator) on 12/07/22. She acknowledged the findings. The exit doors were toured with Staff 1 and Staff 23 (Maintenance) on 12/05/22. They acknowledged the door alarms needing batteries or repair/replacement.
Based on observation and interview, it was determined the facility failed to ensure a manually-operated emergency call system was provided at each resident bathroom and public-use restroom and exit door alarms or other acceptable system were provided for security purposes and to alert staff when residents exited the facility. This is a repeat citation. Findings include, but are not limited to:1a. Random resident apartments were toured during the revisit survey. Resident rooms 205, 233, 311, 313 and 333 did not have a manually-operated emergency call system in the unit bathrooms.b. Public restrooms on the 1st and 2nd floors had wireless emergency call devices. However, when the 2nd floor restroom device was activated, it did not notify the staff iPod devices. In an interview on 05/24/23, Staff 9 (Facility Administrator) acknowledged the facility had recently upgraded its wifi system but the wireless wall-mounted devices no longer connected with staff iPods. She stated she would follow-up with the corporate IT department.2. The facility was toured on 05/23/23 at 9:40 am. A door alarm in the north MCC unit and several door alarms in the ALF did not operate when the door was opened.The need to ensure exit door alarms or other acceptable system were provided for security purposes and to alert staff when residents exited the facility was discussed with Staff 9 (Facility Administrator), Staff 32 (Regional Maintenance Director) and Staff 23 (Maintenance) on 05/24/23. They acknowledged the door alarms needing batteries or repair/replacement.

Based on observation and interview, it was determined the facility failed to ensure a manually operated emergency call system was provided at each resident bathroom and public-use restroom and exit door alarms or other acceptable system were provided for security purposes and to alert staff when residents exited the facility. This is a repeat citation. Findings include, but are not limited to:1a. Random resident units in the ALF were toured on 04/15/24 and 04/16/24. Resident rooms 206, 209, and 330 did not have a manually-operated emergency call system in the unit bathrooms.b. Random resident units in the North and South MCC cottages were toured on 04/15/24 and 04/16/24. Resident rooms 120, 122, and 137 did not have a manually-operated emergency call system in the unit bathrooms.c. Public restrooms on the 2nd and 3rd floors of the ALF had wireless emergency call devices. However, when the 2nd floor restroom device was activated, it did not notify the staff iPod devices. During an interview on 04/16/24, Staff 23 (Maintenance) confirmed the wireless push-button call devices in resident bathrooms and in the public bathrooms were inoperable.2. The facility was toured at 9:06 am on 04/15/24. A door alarm in the South MCC unit and several door alarms in the ALF did not operate when the doors were opened.The need to ensure a manually operated emergency call system was provided at each resident bathroom and public-use restroom and exit door alarms or other acceptable systems were provided for security purposes and to alert staff when residents exited the facility was discussed with Staff 9 (Director of Facility Operations) on 04/16/24. She acknowledged the findings.


Based on observation and interview, it was determined the facility failed to provide a call system that connected resident units to the care staff center or staff pagers and failed to provide manually operated emergency call systems at each resident bathroom and public-use restrooms. Residents were unable to contact staff to request help when needed, constituting a threat to their health, safety, and welfare. This is a repeat citation. Findings include, but are not limited to:During a re-licensure survey in 12/2022, facility staff were made aware that resident bathrooms in the MC and AL communities did not have manually operated emergency call systems. Subsequent re-visit surveys in 05/2023 and 04/2024 identified the same concerns and facility staff were made aware.On 09/17/24 and 09/18/24 during a re-licensure re-visit, the memory care and assisted living communities were toured and interviews with facility staff and residents were conducted, the following was identified:a. Multiple assisted living unit bathrooms were observed to lack a manually operated emergency call system. Interviews with multiple direct-care staff, identified these unit bathrooms previously had an emergency call system, but it was removed a "long time ago."Multiple memory care unit bathrooms were identified to have a white circular push button mounted on the wall. Interviews with multiple direct-care staff identified the emergency call system was inoperable. Public bathrooms located throughout the facility were identified to have a white circular push button mounted on the wall. Interviews with facility staff determined the emergency call system was inoperable.On 09/18/24 at 9:47 am, Staff 23 (Maintenance) reported the emergency call system provided at each resident bathroom was removed several years ago in both the memory care and assisted living communities and was aware the public bathrooms did not have an operable emergency call system.b. Several direct care staff interviewed on both the memory care and assisted living units stated assisted living residents were provided an emergency call pendant that would notify staff when used. However, each confirmed the memory care residents were not provided with pendants.On 09/18/24 at 9:33 am, Staff 23 confirmed the memory care residents were not provided a pendant and did not have a call system that connected the resident or the resident unit to the facility staff.On 09/18/24 at 10:26 am, Staff 2 (Corporate Director of Nursing/Administrator) and Staff 37 (Corporate Director of Wellness) confirmed they were aware the facility did not have an operable call system. The facilities failure to ensure residents had a working call system, left residents unable to call for assistance when needed and placed the residents health, safety, and welfare at risk. On 09/18/24 at 11:29 the facility was asked to complete and provide an immediate plan of correction. The plan of correction was received and accepted at 3:34 pm. The facility plan of correction included hourly checks for all residents until full installation of a new system was completed by 09/30/24. The immediate risk was addressed, however the facility will need to evaluate the overall system(s) failures(s) associated with the licensing violation. The need to have an operational call system that connected residents to the care staff center or staff pagers and to have a manual emergency call system in all resident bathrooms including public restrooms was discussed with Staff 2, Staff 23, Staff 37, Staff 38 (Resident Services Director), Staff 39 (Director of the Cottages), and Staff 40 (LPN) on 09/18/24. They acknowledged the findings.Facility failed to ensure a manually operated emergency call system was provided at each resident bathroom and public-use restroom1. All rooms audited to ascertain functionality of manually operated call system. A call system that is secured to the bathroom wall will be installed in all resident rooms and public-use restrooms. Malfunctioning units will be repaired or replaced. 2. Maintenance Director or designee will monitor devices on an ongoing basis to ensure functionality. 3. Administrator or designee will perform regular walking rounds with random tests to ensure resident and public use restroom call systems are functioning properly 4. Administrator is responsible to see that the plan of correction meets acceptable standards.

Based on 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 C240, C242, C295, C361, C372, C420, C422, C610, C613, C645 and C655.
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 C361, C372, C420, C422, C610, C613, C615, C645 and C655.
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 150, C 156, C 231, C 420, C 422, C 455, C 610, C 613, C 615, and C 655.

Based on observation 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 150, C 156, C 455, C 610, and C 655.

Refer to C150, C156, C455, C610, C655

Based on interview and record review, it was determined the facility failed to provide required training for 2 of 2 sampled newly-hired non-direct care staff (#s 28 and 21), 3 of 3 sampled newly-hired direct care staff (#s 29, 30 and 8) and 3 of 3 sampled long-term direct care staff (#s 11, 31 and 22) whose training records were reviewed. Findings include, but are not limited to:The building consisted of an Assisted Living Facility that included two endorsed MCC units that fell under the same license. In an interview on 12/06/22, Staff 1 (Interim Administrator) and Staff 2 (Corporate Director of Nursing) stated the facility provided training for staff as required under the MCC rules (OAR 411-057-0155) so that all staff had knowledge of dementia care, regardless of whether they worked in the MCC units or the ALF.Staff training records were reviewed on 12/06/22. The following deficiencies were identified:1. Staff 28 (Housekeeping) and Staff 21 (Dietary Cook) were hired on 06/01/22 and 10/04 22, respectively.* There was no documented evidence Staff 28 and Staff 21 completed the required orientation and pre-service dementia training, were provided written job descriptions or that Staff 21 completed Oregon Food Handler's training prior to beginning their job duties.2. Staff 29 (CG) was hired 08/16/22, Staff 30 (MT) was hired 09/16/22 and Staff 8 (CG) was hired 09/24/22.* There was no documented evidence Staff 30 and Staff 8 completed orientation training prior to beginning their job duties and pre-service training prior to working independently, or were provided written job descriptions.* Staff 29 lacked documentation of having completed the following orientation and pre-service training: * Infectious Disease Prevention training; * Environmental factors that are important to a resident's well-being; * Family support and the role the family may have in the care of the resident; * How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment; * How to provide personal care to a resident with dementia, including orientation to the resident's service plan; and * Use of supportive devices with restraining qualities in memory care communities.* Staff 29, 30 and 8 lacked documentation of demonstrated competency in any duty they are assigned.3. Staff 11 (MT) was hired 02/25/08, Staff 31 (CG) was hired 08/17/17 and Staff 22 (MT) was hired 06/18/15. Annual training records were reviewed for the last twelve month period from each staff person's anniversary date of hire.* Staff 11 and Staff 31 lacked documented evidence they completed a minimum of 16 hours of annual in-service training on topics related to the provision of care for persons in a community-based care setting including six hours of annual in-service training on dementia care.* Staff 11, 31 and 22 lacked documented evidence they completed annual in-service training on infectious disease prevention by July 1, 2022.The need to ensure all staff completed all required training as specified in the rules was reviewed with Staff 1 and Staff 2 on 12/07/22. They acknowledged the findings. The surveyor provided them a copy of OAR 411-057-0155.
Based on interview and record review, it was determined the facility failed to provide required orientation training for 2 of 2 sampled newly-hired Staff (#s 33 and 34), pre-service training for 1 of 1 sampled newly-hired direct care Staff (#33) and have documentation of demonstrated competency in all required job duties for 1 of 1 sampled newly-hired direct care Staff (#33) whose training records were reviewed. This is a repeat citation. Findings include, but are not limited to:The building consisted of an Assisted Living Facility that included two endorsed MCC units that fell under the same license. In an interview on 05/24/23, Staff 9 (Facility Administrator) stated the facility provided training for staff as required under the MCC rules (OAR 411-057-0155) so that all staff had knowledge of dementia care, regardless of whether they worked in the MCC units or the ALF.Staff training records were reviewed on 05/24/23. The following deficiencies were identified:1a. Staff 33 (MT) was hired 01/24/23. There was no documented evidence s/he completed orientation training on the topic of resident rights and values of Community-Based Care or received a copy of their job description prior to performing any job duties. The other required orientation topics (abuse reporting requirements, infectious disease prevention and fire safety and emergency procedures) were not completed prior to performing job duties as required.b. Staff 34 (Dining Server) was hired 02/01/23. There was no documented evidence s/he completed orientation training on the topic of infectious disease prevention or received a copy of their job description prior to performing any job duties.2. There was no documented evidence Staff 33 completed training in the following pre-service topics prior to providing care and services to residents independently:* Environmental factors that are important to a resident's well-being;* Family support and the role the family may have in the care of the resident;* How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment;* How to provide personal care to a resident with dementia, including orientation to the resident's service plan; and* Use of supportive devices with restraining qualities in memory care communities.3. There was no documented evidence Staff 33 demonstrated knowledge and performance in all required areas, including medication administration, within the first 30 days of hire.The need to ensure newly-hired staff completed all required orientation, pre-service and competency training within the required timeframe's was reviewed with Staff 9 (Facility Administrator) on 05/24/23. She acknowledged the facility still needed to review and improve its training process to ensure compliance.

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 C260, C262, C270, C282, C290, C303, C340 and C310.
Based on observation, interview and record review, it was determined the facility failed to follow health care rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C260, C270, C280, C282, C310 and C330.

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 260, C 270, C 282, and C 330.

Based on interview and record review, it was determined the facility failed to ensure individualized activity plans were developed for each resident, based on their activity evaluations, for 2 of 2 sampled memory care residents (#s 5 and 6) whose service plans were reviewed. Findings include, but are not limited to:Resident 5 was admitted to the MCC in 07/2019 with diagnoses including Alzheimer's Disease, atrial fibrillation and depression, and Resident 6 was admitted to the MCC in 04/2020 with diagnoses including vascular dementia, emphysema and hypertension.Residents 5 and 6's service plans offered some information about the residents' historical and current interests. However, the facility had not fully evaluated the residents in the following areas:* 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.There were no specific activity plans developed from the evaluations which detailed what, when, how and how often staff should offer and assist the resident with individualized activities.On 12/07/22 the need to ensure the facility developed individualized activity plans for each resident in the MCC was discussed with Staff 1 (Interim Administrator) and Staff 3 (RN Director of The Cottages) who acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure individualized activity plans were developed for each resident, based on their activity evaluations, for 1 of 1 sampled memory care resident (#5) whose service plan was reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 5 was admitted to the MCC in 07/2019 with diagnoses including Alzheimer's Disease, atrial fibrillation and depression.Residents 5's record offered information about the residents' historical interests. However, the facility had not fully evaluated the resident in the following areas:* 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.There were no specific activity plans developed from the evaluation which detailed what, when, how and how often staff should offer and assist the resident with individualized activities.On 05/23/23 the need to ensure the facility developed individualized activity plans for each resident in the MCC was discussed with Staff 9 (Facility Administrator) and Staff 35 (RN) who acknowledged the findings.