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 conduct investigations of injuries of unknown cause to rule-out abuse or report the injuries as suspected abuse to the local Seniors and People with Disabilities (SPD) office, for 1 of 2 sampled residents (#2) with injuries of unknown cause. Findings include, but are not limited to: Resident 2 was admitted to the Memory Care Facility in 2021 with diagnoses which included dementia and required staff assistance with ADL care needs. Facility Observation Notes, reviewed from 07/01/25 through 09/09/25, revealed the following: * On 07/30/25, staff documented that the resident had “slight bruising/swelling to the corner of brow of the right eye…"; and * On 08/28/25, the resident was found with a "small cut on the right middle knuckle of the right hand…" There was no documented evidence the facility immediately investigated and documented that the injuries were not the result of abuse or neglect, or evidence the facility reported the injuries to the local protective services office as suspected abuse/neglect. Additional information was requested from Staff 1 (MCC Administrator) on 09/10/25 at 10:15 am. On 09/10/25, Staff 1 informed the surveyor that the injuries had not been investigated to rule out abuse or neglect. The need to ensure injuries of unknown cause were investigated promptly or reported if necessary was discussed with Staff 1. She stated she would investigate the incidents and report the injuries to the local protective services office. Verification that the facility had reported the incidents to the local SPD office was received during the survey.

1. Immediate action taken was: incident report filed, and investigation completed and turned into local APD office. As of 09/16/2025 we received notice that this was screened out for investigation. 2. RCC, Admin and/or LN's will read observation notes daily Monday through Friday at daily clinical meeting for 2 weeks and then ongoing will monitor observation notes no less than once weekly. The med-techs will be in-serviced on what incidents are required to be reported. 3. Observation notes will be monitored by administrator no less than weekly for any reports of injuries of unknown cause that do not have a correlating incident report. 4. Administrator will evaluate weekly, if administrator unable to perform audit the Wellness Director will audit observation notes.

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 medication and treatment orders were carried out as prescribed for 1 of 2 sampled residents (#2) whose orders were reviewed. Findings include, but are not limited to: Resident 2 was admitted to the MCC in 2022 with diagnoses which included dementia and was receiving hospice services as of the survey. Physician orders and MARs, reviewed from 08/01/25 through 09/09/25, revealed the following orders were not followed: * Knee immobilizer, to be placed on the left knee during the day, was not applied on nine occasions; and * Haldol (for agitation) 1 mg one tablet at noon and bedtime was not administered at noon on 08/01/25, 08/02/25 and 08/03/25 because it was unavailable. However, the bedtime dose was administered during the same time frame. In an interview with Staff 2 (MCC RCC) and Staff 4 (LPN Wellness Director) on 09/10/25 at 3:00 pm, they acknowledged that staff failed to administer the noon dose of Haldol as ordered. The need to ensure orders were carried out as prescribed was reviewed with Staff 1 (MCC Administrator) and Staff 5 (Campus Administrator) on 09/11/25. They acknowledged the findings.

1. Med-Tech that was involved in the missing charting has been in-serviced on expectations of documentation and ensuring that physician's orders are carried out as prescribed. 2. RCC's currently check for holes in the MAR no less than weekly. Refusal and missing med reports are pulled daily to ensure follow up of any documentation errors. 3. Going forward this will be evaluated daily with refusal and missed med reports daily, and additionally the Wellness director and/or administrator will monitor reports weekly. 4. The administrator and wellness director will be responsible to follow up weekly and ensure that RCC's have pulled daily refusal and missing med reports and follow up accordingly.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was maintained and PRN parameters were followed for all facility administered medications for 2 of 2 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted in 2021 with diagnosis which included dementia and was receiving hospice services as of the survey. Resident 1 had orders for: * Sertraline HCL 25 mg one tablet twice a day for dementia. According to the MARs, reviewed from 08/01/25 through 09/09/25, staff documented on multiple occasions between 08/29/25 through 09/02/25, that the medications were not available. However, there were also two occasions that staff initialed the medications were administered during the same time frame. The discrepancies on the MAR were reviewed with Staff 1 (MCC Administrator) on 09/10/25 at 11:25 am. She confirmed that staff initialed that the medications had been administered when they were unavailable. She acknowledged the MAR was inaccurate. 2. Resident 2 moved into the MCC in 2022 with diagnoses which included dementia and was receiving hospice services as of the survey. Resident 2 had orders for the following: * Lorazepam 0.5 mg one tablet every two hours as needed for anxiety. Staff were instructed to call Hospice prior to administration; * Haloperidol 2 mg one tablet every two hours as needed for uncontrolled agitation, nausea, or vomiting. Staff were instructed to call Hospice prior to administration; and * Morphine Sulfate 20mg/1ml, give o.5 ml every hour as needed for severe pain or shortness of breath. Staff were instructed to call Hospice prior to administration. The residents MARs and clinical record were reviewed from 08/01/25 through 09/09/25. According to the MARs, the PRN Lorazepam, Haloperidol and Morphine was administered by staff on several occasions without documentation that hospice was called before the medications were given to the resident. Additional information was requested during the survey. In an interview on 09/11/25 at 10:15 am, Staff 2 (MCC RCC) and Staff 4 (LPN Wellness Director) stated they were unable to find documentation that staff consistently called hospice prior to administering the PRN medications. They acknowledged the parameters were not followed. The need to ensure PRN parameters were followed was reviewed with Staff 1 (MCC Administrator) and Staff 5 (Campus Administrator) on 09/11/25. They acknowledged the findings.

1. Med-Tech that performed inaccurate charting of resident #1's medications has been in-serviced on the expectations and requirements of accurate charting. Med-Techs that did not chart on the appropriate interventions for resident #2's medications have been inserviced on the expectations and requirements of accurate charting and including interventions when providing PRN medications. Additionally, all Med-Techs are required to phone administrator if at any time medications are not in the community. 2. Any missing medicaitons charting will be reviewed by RCC's daily. Going forward, any medications that require interventions will have additional questions through the electronic charting that are required before passing the medications. 3. RCC's will continue daily missed med reports and therefore respond accordingly. Each new PRN order will be evaluated as it is prescribed and will have questions input on 3rd check by Wellness Director. 4. Administrator and Wellness Director will be responsible to respond to daily reports made by RCC's regarding missed medications. Wellness Director and/or administrator will be responsible to audit PRN medications.

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 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 C231, C303, and C310.

This tag is referall tag to plan of correction for all other tags.