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 observation, interview, and record review, it was determined the facility failed to ensure residents were treated with dignity and respect and failed to provide a safe and homelike environment related to courtyard access for 2 of 2 sampled residents (#s 1 and 2) and non-sampled residents. Findings include, but are not limited to: Observations of the resident courtyard on 12/02/24 and 12/03/24 showed the following: * There were double doors on each side of the dining room which led to the outdoor courtyard, gazebo, and resident smoking area. * The doors remained locked throughout the day/evening. Residents who went out to the courtyard had to utilize their key to come back into the facility. * The main entrance was unlocked throughout the day and early evening. The door opened automatically when people approached. * Multiple residents utilized the smoking area and courtyard throughout the day/evening. Residents who were in wheelchairs struggled to get the door unlocked and opened and to maneuver their wheelchairs through the doorway. * Staff assisted with opening the door if they were nearby and observed residents struggling. * Resident 1 had multiple scabbed areas on his/her hands and feet. Interviews conducted between 12/02/24 and 12/03/24 showed the following: Resident 1 indicated s/he had a very difficult time getting in and out the door on his/her own. The door did not have an automatic opening feature. The resident indicated it was most difficult getting back in because the doors were locked. S/he had to get the door unlocked with his/her key and then try to pull the door open, hold it, and drive his/her electric wheelchair through the door. Resident 1 indicated s/he had bumped hands and feet repeatedly and had several scrapes, scabs and/or bruises from trying to get through the door. The resident went outside frequently to the smoking area and found it “extremely frustrating” to be unable to get in and out the door on his/her own without some kind of issue. Resident 2 indicated s/he went outside throughout the day. S/he stated the doors were all locked so must take his/her key with him/her to get back inside or would need to come around to the front door, which would be unlocked. The resident stated s/he sometimes went out the front and around to his/her preferred location and other times went out the dining room doors or the door at the end of the hall. Resident 2 stated s/he usually went out in his/her electric wheelchair but had gone out in the manual wheelchair as well. The resident indicated it was difficult to get in and out the doors in the dining room as well as the doors at the end of the halls. The resident indicated s/he had a fall from his/her wheelchair several weeks ago trying to get back in one of the locked doors. Non-sampled residents from the group interview and general observation of the facility indicated the doors were all kept locked, required their keys to get back into the facility, and were difficult to maneuver while trying to get back into the facility. Two residents indicated issues specifically with the front door being locked at night, as well. Staff 18 and 19 (CGs) indicated the doors were kept locked for safety. The residents all had keys and also had call pendants to wear. The staff further indicated if a resident needed help coming in or while they were outside, they could just push their pendant. Staff 1 (Administrator) indicated the doors were kept locked for safety, as there had been transients trying to enter the facility. All the residents had keys and could use their pendants for assistance as well. Staff 1 indicated they would look at other options for the doors. Staff 3 (Wellness Director/LPN) indicated Resident 1 had several skin issues related to bumping into multiple areas in the facility. Staff 3 further indicated Resident 2 did have a fall out of his/her wheelchair while trying to get back into the facility but was unsure if it was from the courtyard or a door at the end of the hall. The need to ensure residents were treated with dignity and respect, had a safe and home like environment and were able to easily access the courtyard and outdoors without creating an increased risk for injury was discussed with Staff 1, Staff 2 (Wellness Coordinator/RN), Staff 3, and Staff 4 (Wellness Coordinator/LPN) on 12/05/24. The staff acknowledged the findings.

After discussion with the policy analyst, doors will remain unlocked during business hours, bids are being obtained for a key/automatic entry pad for outside and automatic button to open the doors from the inside. This will make accessibility easier for residents to enter and exit and still keep the residents safe from outside people roaming the building undetected. After hours the residents will use their pendent to get in. Doors will be checked daily to ensure they are unlocked during business hours.

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 evaluations were reflective of the needs and current condition of 2 of 7 sampled residents (#s 1 and 5) whose evaluations were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 09/2023 with diagnoses including multiple sclerosis, myasthenia gravis, post-polio syndrome, and history of malnutrition. The resident's most recent evaluation, dated 11/06/24, was reviewed, interviews were conducted, and the resident was observed. Multiple areas of the evaluation did not describe Resident 6's current physical and mental status, environmental factors which helped the resident function at his/her optimal level, and/or were not reflective of the resident's current condition, including: * Hospital admission within the past 12 months; * Non-pharmacological interventions for pain; * Behaviors, including suicidal ideation; * Confusion; and * Level of assistance required with transfers, ambulation, grooming, dressing, personal hygiene, and meals. The need to ensure evaluations described resident's physical health status, mental status, and the environmental factors that helped the resident function at their optimal level, and were reflective of the current needs and condition of the resident, was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/RN), Staff 3 (Wellness Director/LPN), and Staff 4 (Wellness Coordinator/LPN) at 2:05 pm on 12/05/24. They acknowledged the findings. 2. Resident 1 was admitted to the facility in August 2022 with diagnoses including chronic obstructive pulmonary disease. The resident’s most recent smoking evaluation, dated 10/31/24, observation notes 09/02/24 through 11/24/24, and alert charting notes 09/03/24 through 12/02/24 were reviewed. Observation notes in September 2024 and October 2024 reflected five occasions in which the resident was slumped over or asleep in his/her wheelchair while outside in or near the smoking area. On one occasion the resident dropped his/her cigarette onto the blanket on his/her lap. Staff observed this and intervened, and no injury was sustained. The resident was a frequent smoker, and no burn injuries were documented for the resident during the look-back period. Additionally, no burn holes had been noted to his/her clothing or lap blanket. Additional observation notes for the month of October 2024 reflected four occasions in which the resident was found to be smoking in his/her apartment or was suspected of smoking in the facility. The smoking evaluation did not accurately reflect the resident’s recent history of nodding off while outside, dropping a cigarette into their lap, and smoking in his/her apartment and/or elsewhere within the facility interior. In an interview on 12/05/24, Staff 2 (Wellness Coordinator/RN) indicated the resident’s drowsiness was strongly related to low oxygen saturations and some medication issues at the time. The resident currently was doing much better with oxygen compliance, and the sleepiness and nodding off had improved. In an interview on 12/05/24, Staff 3 (Wellness Director/LPN) indicated the resident had experienced a significant change at the time the smoking evaluation was updated. The resident currently was not nodding off while smoking and was not attempting to smoke indoors. Staff 3 understood the need to complete an updated smoking evaluation, with all areas of potential concern addressed regarding the resident’s ability to independently smoke at the time of a significant change or other assessment. The need to ensure smoking evaluations contained all pertinent information related to the resident’s safe smoking ability was discussed with Staff 1 (Administrator), Staff 2, Staff 3, and Staff 4 (Wellness Coordinator/LPN) on 12/05/24. The staff acknowledged the findings.

The wellness director and nursing team will make sure all sub assessment evaluations are accurate IE: smoking, at all quarterly evaluations and with all changes of condition. CP for resident 6 were updated for hospitalization, etc. and resident 1 for smoking unsafely. Wellness director and team will update with every Change of condition going forward. System will be evaluated at clinical daily meetings.

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction regarding the delivery of services, and services were implemented for 5 of 7 sampled residents (#s 1, 2, 5, 6, and 8) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 8 was admitted to the facility in 07/2021 with diagnoses including heart failure and atrial fibrillation. The resident's current service plan, dated 12/02/24, was reviewed, observations were made, and interviews with the resident and staff were conducted between 12/02/24 and 12/05/24. Resident 8's service plan was not reflective or did not provide clear direction to staff in the following areas: * Alcohol-related behaviors, including resistance to care; * Preference to sleep in her/his recliner chair; and * Preference for front door to be open with a pet gate. The need to ensure service plans were reflective of resident's current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 3 (Wellness Director/LPN), and Staff 4 (Wellness Coordinator/LPN) on 12/05/24. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 08/2022 with diagnoses including chronic obstructive pulmonary disease and chronic pain. Observations of the resident, interviews with staff, and review of the resident's service plan dated 10/31/24, observation notes dated 09/02/24 through 11/24/24, and alert charting notes dated 09/03/24 through 12/02/24 were completed. Staff indicated the resident had recurrent issues with low oxygen levels and grogginess. The resident could make his/her needs known and direct his/her own care. Staff stated the resident frequently ran into things when groggier. The resident needed one staff assistance for ADL needs. The resident’s service plan was not reflective, lacked resident-specific direction for staff, and/or was not consistently implemented by staff in the following areas: * Falls and safety interventions; * Evacuation assistance and process; * Walker use and transfers for care; * Smoking safety, tobacco use, marijuana use, and assistance needed; * Oxygen use including liters required and resident compliance; * Dressing, toileting, and incontinent assistance; * Compression stockings; * Chronic pain, prn medications, and non-drug interventions; * Shower assistance and hospice services; and * Edema, weight fluctuations, and intake. The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and were consistently implemented was discussed with Staff 1 (Administrator), Staff 2 (Wellness Director/RN), Staff 3 (Wellness Director/LPN), and Staff 4 (Wellness Director/LPN) on 12/05/24. The staff acknowledged the findings. 3. Resident 2 was readmitted to the facility in 11/2024 with diagnoses including bipolar disorder and hallucinations. Observations of the resident, interviews with staff, and review of the resident's service plan dated 11/21/24, observation notes dated 09/03/24 through 12/02/24, and alert charting notes dated 09/02/24 through 12/02/24 were completed. Staff indicated the resident could direct his/her own care and make needs known. The resident had a fractured foot with a walking boot in place. The resident required one person assistance for ADLs and stand by assistance for transfers. The resident was more alert and clearer cognitively since his/her return from the hospital and medication changes made. The resident’s service plan was not reflective, lacked resident-specific direction for staff, and/or was not consistently implemented by staff in the following areas: * Suicidal statements; * Walking boot use and fractured foot; * Falls and safety interventions; * Neck brace; * Transfer assistance for toileting; * Evacuation assistance and process; * Auditory and visual hallucinations; * Electric wheelchair care and use; * Smoking safety, tobacco use, marijuana use, and assistance needed; * Dressing, toileting, and incontinent assistance. The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and were consistently implemented was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/RN), Staff 3 (Wellness Director/LPN), and Staff 4 (Wellness Coordinator/LPN) on 12/05/24. The staff acknowledged the findings. 4. Resident 6 was admitted to the facility in 07/2020 with diagnoses including diabetes (Type 2), chronic obstructive pulmonary disease, and hypertension. Review of clinical records revealed Resident 6’s service plan, dated 11/22/24, was not reflective of current resident status or did not provide clear direction for staff in the following areas: * Destructive/abusive behaviors; and * Use of psychotropic medications. On 12/05/24 at 11:15 am, the need to ensure service plans were reflective of current resident status and care needs, and provided clear direction for staff was discussed with Staff 1 (Administrator) and Staff 3 (Wellness Director/LPN). They acknowledged the findings. 5. Resident 5 was admitted to the facility in 09/2023 with diagnoses including multiple sclerosis, myasthenia gravis, post-polio syndrome, and history of malnutrition. The resident's 11/06/24 service plan and 09/03/24 through 12/02/24 temporary service plans were reviewed, interviews with staff and the resident were conducted, and observations were made. The resident's service plan was not reflective of needs and preferences, did not provide clear direction to staff, and/or was not implemented in the following areas: * Diet texture; * Transfers; * Suicidal ideation; * Communication, including use of white board; and * Confusion. The need to ensure service plans were reflective, provided clear direction to staff, and were implemented was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/RN), Staff 3 (Wellness Director/LPN), and Staff 4 (Wellness Coordinator/LPN) at 2:05 pm on 12/05/24. They acknowledged the findings.

Wellness director and nurses will ensure all service plans do not have prepopulated information and will be updated to accurately reflect resident preferences and needs quarterly and at all Changes of Condition, Resident 8 was missing alchohol related behaviors, resistent to care have been updated and will be updated at clinical meetings. Residen 1, 2, 6 and 5 have been updated. All care plans will be discussed at clinical meetings with the nursing team, wellness director and administrator will be monitoring effectiveness of system at daily meetings.

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 observation, interview, and record review, it was determined the facility failed to ensure residents who experienced short-term changes of condition had resident-specific actions or interventions determined and documented, and residents' changes of condition were monitored consistent with evaluated needs, with progress noted at least weekly to resolution, for 2 of 6 sampled residents (#s 1 and 5) who experienced changes of condition. Resident 5 had ongoing weight loss which constituted a risk to the health, safety, and welfare of the resident. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 09/2023 with diagnoses including multiple sclerosis, myasthenia gravis, post-polio syndrome, and history of malnutrition. The resident's service plan available to staff, dated 11/06/24, temporary service plans dated 09/03/24 through 12/02/24, 11/01/24 through 12/02/24 MARs, progress notes dated 09/03/24 through 12/02/24, and weight records dated 05/01/24 through 12/05/24 were reviewed, observations were made, and interviews with staff and the resident were conducted. a. Review of Resident 5's weight records revealed the following: * 05/01/24 – 134.6 pounds; * 06/03/24 – 135.6 pounds; * 07/2024 through 10/2024 – no record of weight documented; * 11/06/24 – 115.4 pounds; * 11/12/24 – 116.2 pounds; and * 11/19/24 - 117 pounds. Between 05/01/24 and 11/06/24 Resident 5 experienced a severe weight loss of 19.2 pounds, or 14% of his/her total body weight in 6 months. This constituted a severe weight loss and a significant change of condition. There was no documentation that the facility evaluated the resident, referred the weight loss to the facility nurse, documented the change, and updated the service plan. The resident was weighed at survey request on 12/05/24 and weighed 111.6 pounds, an additional weight loss of 5.4 pounds since 11/19/24. During the survey, 12/02/24 through 12/05/24, the resident was able to eat independently and was observed to consume 100 percent of his/her meals in either the dining room or his/her apartment. S /he ate three meals per day, confirmed by facility staff. Dining staff stated the resident at times had difficulty swallowing, so all food was cut up when s/he ate in his/her room but was left whole when able to be monitored in the dining room. Staff 10 (MT) and Staff 12 (MT) confirmed that the resident had trouble swallowing and all medications were administered crushed and in yogurt. The resident was not observed choking or coughing while survey observed meals. During an interview at 11:15 am on 12/05/24, Staff 3 (Wellness Director/LPN) and Staff 4 (Wellness Coordinator/LPN) confirmed that there was no documentation that the resident was evaluated and referred to the RN for his/her weight loss or that the service plan was updated related to the weight loss. The resident experienced a significant change of condition, severe weight loss. There was no documentation that the facility evaluated the resident, referred the weight loss to the facility nurse, documented the change, and updated the service plan. The resident continued to lose weight, which constituted a risk to the health, safety, and welfare of the resident. b. The following short-term changes of condition, documented in the progress notes, lacked actions or interventions communicated to staff on all shifts and/or were not monitored at least weekly to resolution: * 10/09/24 – New medication; * 10/18/24 – Suicidal ideation; * 11/08/24 – Unwitnessed fall; * 11/17/24 – Missed medications and difficulty swallowing; and * 11/23/24 – Unwitnessed fall. The need to ensure all changes of condition had actions or interventions developed, implemented, communicated to staff on all shifts, and were monitored at least weekly to resolution was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/RN), Staff 3, and Staff 4 at 2:05 pm on 12/05/24. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 08/2022 with diagnoses including chronic obstructive pulmonary disease. The resident's 10/31/24 service plan, 09/02/24 through 11/24/24 observation notes, alert charting notes, and physician communications were reviewed. The resident experienced multiple short-term changes without noted progress at least weekly until resolved, lacked resident-specific directions to staff, and/or did not reflect evaluation of interventions for effectiveness in the following areas: * Unresponsiveness/drowsiness related to medication use, low oxygen saturation levels, and marijuana/THC use; * Power chair operation while drowsy with multiple crashes into objects; and * Drowsiness/falling asleep while in the smoking area attempting to smoke. The need to ensure short-term changes of condition had documentation of weekly progress until resolution, provided clear, resident-specific directions to staff, and interventions were evaluated for effectiveness was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/RN), Staff 3 (Wellness Director/LPN) and Staff 4 (Wellness Coordinator/LPN) on 12/05/24. The staff acknowledged the findings.

RN is responsible for weekly charting on all Changes of condition. All changes of Condition will be discussed in daily clinical meeting. Resident 5 all instances of weight loss, gain, meds and suicidal ideations have been addressed. RN is doing nurse learn and will finish module 2, pertaining to weight changes and Significant changes of condition and certificate will be in the binder.

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 a significant change of condition assessment was completed by the RN, which included findings, resident status, and interventions, for 1 of 6 sampled residents (#5) who experienced significant changes of condition. The resident experienced ongoing weight loss which constituted a risk to the health, safety, and welfare of the resident. Findings include, but are not limited to: Resident 5 was admitted to the facility in 09/2023 with diagnoses including multiple sclerosis, myasthenia gravis, post-polio syndrome, and history of malnutrition. Resident 5’s weight records revealed that between 05/01/24 and 11/06/24 s/he experienced a severe weight loss of 19.2 pounds, or 14% of his/her total body weight in 6 months. The resident was weighed at survey request on 12/05/24 and weighed 111.6 pounds, an additional weight loss of 5.4 pounds since 11/19/24. This constituted a severe weight loss and a significant change of condition. There was no documented evidence an RN completed an assessment of the severe weight loss including findings, resident status, and interventions made as a result of the assessment and the resident continued to lose weight. The need to ensure all significant changes of condition were assessed by an RN, with documented findings, resident status, and interventions made as a result of the assessment, was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/RN), Staff 3 (Wellness Director/LPN), and Staff 4 (Wellness Coordinator/LPN) at 2:05 pm on 12/05/24. They acknowledged the findings. Refer to C270, example 1a.

RN will assess and chart on all Changes of Condition within 48 hours and chart weekly progress. This will be discussed in our daily clinical meetings with the team Significant COC for resident has been complete and module 2 nurse learn will be completed with certifcate in the binder.

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 MARs were accurate and provided resident-specific parameters and staff instruction for 5 of 7 sampled residents (#s 2, 3, 5, 6, and 7) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 7 was admitted to the facility in 02/2012 with diagnoses including Type 2 diabetes. Resident 7's 11/01/24 through 12/02/24 MARs were reviewed, and the following was identified: The MAR directed staff to subcutaneously administer insulin glargine (long-acting insulin) bid and Humalog (fast-acting insulin) tid depending on the resident’s blood sugar and meal intake. The MARs revealed that staff documented the insulin doses but had not documented the location of the injections. In an interview on 12/05/24 at 11:35 am with Staff 2 (Wellness Coordinator/RN) and Staff 3 (Wellness Director/LPN), it was confirmed that staff had not been documenting the sites of the insulin injections. On 12/05/24, the need to ensure accurate documentation of the MAR was discussed with Staff 2 and Staff 3. They acknowledged the findings. 2. Resident 6 was admitted to the facility in 02/2022 with diagnoses including Diabetes (Type 2), chronic obstructive pulmonary disease, and hypertension. Review of Resident 6’s MAR, dated 11/01/24 through 12/02/24, identified the following: a. The MAR lacked resident-specific parameters for use of the following PRN pain medications, and PRN bowel medications: * The PRN medications for constipation were acetaminophen 650 mg supp, bisacodyl 10 mg supp, and Senna 8.6 mg tab. There were no instructions for the sequential order of administration of these medications; and * The MAR listed two PRN pain medications. These were acetaminophen 325 mg tab (for pain or fever) and morphine sulfate 20 mg/ml sol (for pain or shortness of breath). The MAR lacked instructions for the sequential order of use of these medications. b. Resident 6 was receiving subcutaneous insulin injections, with Humalog per sliding scale and routine Glargine. The MAR lacked documentation of injection sites for these administrations. On 12/05/24 at 11:15 am, the need to keep an accurate MAR which provided resident-specific parameters and clear instructions for staff was discussed with Staff 1 (Administrator) and Staff 3 (Wellness Director/LPN). They acknowledged the findings. 3. Resident 5 was admitted to the facility in 09/2023 with diagnoses including multiple sclerosis, myasthenia gravis, post-polio syndrome, and history of malnutrition. Review of the resident's 11/01/24 to 12/02/24 MARs and physician orders dated 11/06/24 to 12/02/24 revealed the following: a. Two medications on 11/24/24 and three medications on 11/28/24 were not initialed as administered. There was no indication whether the medication had been administered. b. PRN medications for shortness of breath lacked resident-specific parameters for administration: * Albuterol HFA 90 mcg inhaler; * Iprat Albuterol 0.5-2.5 mg/3 ml nebulizer; and * Morphine sulfate 20 mg/ml solution. The need to ensure the MAR was accurate and PRN medications contained resident-specific parameters and instructions for administration was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/RN), Staff 3 (Wellness Director/LPN), and Staff 4 (Wellness Coordinator/LPN) at 2:05 pm on 12/05/24. They acknowledged the findings. 4. Resident 2 was readmitted to the facility in 11/2024 with diagnoses including chronic pain. Review of the resident's 09/03/24 through 12/02/24 observation notes, physician communications, alert monitoring, and the 11/01/24 and 12/03/24 MARs/TARs showed the following: * The resident had orders for MiraLAX, milk of magnesia, bisacodyl tablet orally, and a bisacodyl suppository. All were ordered daily PRN for constipation. There were no resident-specific parameters for which medication to use first or when to start any of the medications. The need to ensure PRN medications had resident-specific parameters for use was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/RN), Staff 3 (Wellness Director/LPN), and Staff 4 (Wellness Coordinator/LPN) on 12/05/24. The staff acknowledged the findings. 5. Resident 3 was admitted to the facility in 08/2020 with diagnoses including dysphasia. A review of the resident’s 11/01/24 through 12/02/24 MARs/TARs and physician orders identified inaccuracies in documentation. There were a total of 21 blanks on the MARs/TARs for the following medications and treatments: * Daily weights; * Gabapentin (for neuropathy); * Furosemide (for edema); * Hyoscyamine (a gut antispasmodic); * Compression socks (for edema); and * Alert charting. The resident had physician orders for four PRN pain medications. For two of these medications the physician noted the resident was “. . . able to self-direct . . .” Two of the PRN pain medication orders did not include resident-specific parameters regarding the order of administration or indicate the resident was able to self-direct administration. The resident also had four PRN bowel care medications which lacked resident-specific parameters related to the order of administration. The need for the MAR/TAR to be accurate was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/RN), Staff 3 (Wellness Director/LPN), and Staff 4 (Wellness Coordinator/LPN) on 12/05/24 at 2:34 pm. They acknowledged the findings.

All Mars will be checked for accuracy daily at clinical meetings with any holes to be addressed with the med tech responsible and corrective action will be taken. The RCC's, Wellness director and Administrator will oversee this.Resident #7 locations were added to all insulin injections and resident 6 MAR updated to parameters and injection locations, resident 5 missing medications have been fixed. Resident 2 PRN Parameters have been put in for bowel care meds. Resident 3 had missing daily weights. Weekly high risk meetings will be implemented with wellness director leading.

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 interview and record review, it was determined the facility failed to have a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: During the re-licensure survey, 12/02/24 through 12/05/24, the facility’s posted staffing schedule and actual schedules for the period 11/17/24 through 11/30/24 were reviewed. On 10 of 14 overnight shifts, three staff were scheduled and worked. The facility consisted of three floors of resident units. In an interview on 12/05/24 at 5:08 pm, Staff 3 (Wellness Director/LPN) and Staff 4 (Wellness Coordinator/LPN) identified multiple residents on the second and third floors of the facility who would need assistance down the stairs in the event of an emergency evacuation. At the request of survey, the facility agreed to begin immediately scheduling five staff to work the overnight shift, starting on 12/05/24. The need to have an adequate number of direct care staff available on the overnight shift to meet the 24-hour scheduled and unscheduled needs of the residents was discussed with Staff 1 (Administrator), Staff 3 (Wellness Director/LPN), and Staff 4 (Wellness Coordinator/LPN) on 12/05/24. They acknowledged the findings.

Staffing 5 on NOC shift was implemented with use of agency. Administrator reached out to policy analyst and Katie Gaffney and received the latest ABST Provider guide. Administrator and wellness director will check during all quarterly evaluations, all changes of condition and all move ins and move outs.

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 their Acuity-Based Staffing Tool (ABST) accurately captured care time and care elements that staff were providing to residents. Findings include, but are not limited to: A review of the facility’s ABST revealed the care times and care elements documented for cares provided by staff were not accurate for Residents 1, 2, 4, and 6. The need to ensure the ABST accurately captured care time and care elements was discussed with Staff 1 (Administrator), Staff 3 (Wellness Director/LPN), and Staff 4 (Wellness Coordinator/LPN) on 12/05/24. They acknowledged the findings.

Administrator, Wellness Director, and LPN will monitor ABST with all quarterly reviews, COC, move ins and move outs. Provider guide received by Katie Gaffney. Care times for 1, 2, 4 and 6 have been updated.

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 an ABST evaluation was completed or updated for each resident before a resident moved in, whenever there was a significant change of condition, and/or no less than quarterly at the same time the resident’s service plan was updated for 3 of 8 sampled residents (#s 1, 2, and 5) and three unsampled residents. Findings include, but are not limited to: The facility’s ABST was reviewed on 12/04/24. The following was identified: *There was no documented evidence Resident 5 had been entered into the ABST when they moved into the facility; and *Three unsampled residents’ ABST data had not been updated within the last 90 days. The need to ensure all residents are entered into the ABST and reviewed as outlined in the rule was discussed with Staff 1 (Administrator), Staff 3 (Wellness Director/LPN), and Staff 4 (Wellness Coordinator/LPN) on 12/05/24. They acknowledged the findings.

Administrator, Wellness Director, and LPN will monitor ABST with all quarterly reviews, COC, move ins and move outs. Provider guide received by Katie Gaffney

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 3 of 3 direct care staff (#s 11, 15, and 16) demonstrated satisfactory performance in assigned job duties within 30 days of hire and failed to provide documentation that medication technicians had been observed and evaluated as able to perform medication and treatment administration unsupervised prior to completing those tasks. Findings include, but are not limited to: Staff training records were reviewed on 12/03/24 and the following was identified: 1. There was no documented evidence Staff 11 (MT), hired 02/12/24, Staff 15 (CG), hired 08/26/24, and Staff 16 (CG), hired 09/16/24, demonstrated satisfactory performance within 30 days of hire in the following areas: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation, and reporting changes of condition; * Conditions that require assessment, treatment, observation, and reporting; and * General food safety, serving, and sanitation. 2. There was no documented evidence that Staff 11 and Staff 16 demonstrated knowledge and performance in the areas of first aid and abdominal thrust within 30 days of hire. 3. There was no documented evidence, prior to survey entrance on 12/02/24, that staff had observed and evaluated Staff 11’s ability to perform safe medication and treatment administration unsupervised prior to performing the task. During an interview on 12/03/24 at 2:00 pm, Staff 5 (Business Office Manager) stated the facility was not able to locate documentation of competency demonstrated for all MTs administering medications. She stated the competencies had been completed at some time in the past, but the facility was not able to find this documentation. The lack of documentation was confirmed by Staff 1 (Administrator) at 2:45 pm on 12/03/24. As of 4:20 pm on 12/05/24, there was no documented evidence that 9 of 26 MTs scheduled to work in the week of 12/03/24 through 12/10/24 had demonstrated competency in administering medications. Staff 1 stated that Staff 3 (Wellness Director/LPN) and Staff 4 (Wellness Coordinator/LPN) were working with Staff 7 (RCC) and Staff 8 (RCC) to complete documentation with the MTs currently working and planned to make sure all others MTs demonstrated competency prior to administering medications. The need to ensure the facility verified that direct care staff demonstrated satisfactory performance in any duty they were assigned within 30 days of hire was discussed with Staff 1, Staff 2 (Wellness Coordinator/RN), Staff 3, and Staff 4 at 2:05 pm on 12/05/24. They acknowledged the findings.

All competencies have been completed. Competency and training binders have been put together by Administrator and a copy put in employee files. Binders and training documents will be kept up by Business Office assistant with Monthly audits performed.

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory care communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were maintained in good repair and the facility grounds were kept orderly and free of litter and refuse. Findings include, but are not limited to: The exterior grounds of the facility were toured on 12/02/24 at 11:15 am. The following areas were in need of cleaning or repair: * The exterior pathways surrounding the building had multiple drop-offs measuring two to three inches, from the concrete surface to the ground. These drop-offs created a potential tripping hazard for residents; and * There was a covered staff smoking area which contained large barrels for trash and recycling. The floor of this area was littered with trash and debris, including used gloves and cigarette butts. On 12/03/24 at 12:35, the building's exterior was toured with Staff 6 (Environmental Services), and the areas of concern were reviewed. On 12/04/24 at 3:35, the need to ensure all exterior pathways were maintained in good repair, and the grounds were kept orderly and free of litter and refuse was discussed with Staff 1 (Administrator) and Staff 6. They acknowledged the findings.

Bids for repairs have been obtained and submitted to new ownership for approval. Administrator and Maintenance Director will keep up with this project for completion.Approval has been received and repairs are being scheduled. Maintenance will do a daily walk through.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to keep all interior surfaces in good repair. Findings include, but are not limited to: The interior of the building was toured on 12/02/24 at 11:15 am. The following areas were in need of repair: * Scratches on wood cabinet fronts in dining room; * Paint chips and damage to corners of walls in many areas; * Scrapes and scuffs on baseboards in many areas; * Gouges and damage to walls and pillars on second floor landing; * Gaps and small holes in ceiling panels near second floor landing; * Scrapes and damage to two tables in second floor puzzle room; * Dark marks and scratches on doors and door jambs of rooms 118, 131, 135, 231, 240, and 241; * Deep scrapes and gouges on door of first floor elevator; and * Scratches and damage on paneling inside elevator. * Carpet in rooms 315 and 318 showed heavy stains and damage. On 12/03/24 at 12:35 pm the surveyor conducted a tour of the entire facility with Staff 6 (Environmental Services) and reviewed all areas needing repair. On 12/04/24 at 3:35, the need to maintain all interior surfaces in good repair was discussed with Staff 1 (Administrator) and Staff 6. They acknowledged the findings.

Maintenance has been working on all touch up painting in the community. We will have maintenance assistant help and he will walk the outside of the community daily to ensure upkeep.Columns, dining room and common areas are complete. Work will continue on all other areas needing addressed.

OAR411-004-0020(2)(b) Physical Setting: Individual Accessible (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (b) The setting is physically accessible to an individual. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure that residents could physically access their environment for 2 of 2 sampled residents (#s 1 and 2) and multiple non-sampled residents. Findings include, but are not limited to: Residents 1 and 2, as well as several non-sampled residents, indicated they had difficulty physically accessing the resident courtyard due to the doors being locked and no assistive mechanism on the doors. The residents indicated they had to use their key to unlock the door to re-enter the building. Once they got the door unlocked, they then had to attempt to open/hold the door and maneuver their wheelchairs or walkers to get through the doors back into the building. Observations of the courtyard area, dining room doors, and hall doors showed keys were required to re-enter the building from the outside through all the doors. Several residents struggled to get the doors unlocked, opened, and get themselves, their devices, and/or their personal items back indoors. The need to ensure residents could physically access all resident use areas of the facility, regardless of mobility or devices in use, was discussed with Staff 1 (Administrator), Staff 2 (Wellness Coordinator/RN), Staff 3 (Wellness Director/LPN), and Staff 4 (Wellness Coordinator/LPN) on 12/05/24. The staff acknowledged the findings.

A contractor was at the community on 1/3/25 to give a bid for an automatic door and a wireless key entry for the outside. Bid will be here next week and submitted to new ownership for approval. In the meantime after a discussion with the policy analyst the door will remain unlocked during business hours and locked at night for resident safety.