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 resident injuries of unknown cause were immediately investigated to rule out abuse or neglect, and/or reported to the local Seniors and People with Disability (SPD) office for 2 of 2 sampled residents (#s 1 and 2) who had experienced injuries of unknown cause. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 02/2020 with diagnoses including breast cancer, bilateral hip fractures, and osteoporosis. Review of Resident 2’s progress notes, dated 10/14/24 through 01/14/25, revealed the resident had experienced the following: * 12/05/24- Staff discovered a “thumb-sized bruise” on the resident’s right shin. The resident stated s/he did not know how it happened; and * 12/23/24- A bruise was discovered, with “blood pooling beneath skin on left wrist”. The resident stated s/he was unsure how it occurred. There was no documented evidence the facility investigated these incidents to reasonably rule out abuse or neglect. On 01/16/25 at 12:20 pm, Staff 1 (Administrator) verified the incident had not been investigated or reported to the local unit. The surveyor requested the facility report the injuries to the local SPD office. On 01/16/25 at 2:15 pm, the need to investigate resident injuries of unknown cause immediately and report them to the local SPD office if abuse and/or neglect could not be ruled out, was discussed with Staff 1 and Staff 2 (RN). They acknowledged the findings. On 01/17/25 at 9:20 am, Staff 1 presented the surveyor with confirmation the reports had been completed. 2. Resident 1 moved into the facility in 02/2024 with diagnoses including coronary artery disease, vertigo, and PTSD. The resident’s 10/14/24 through 01/14/25 observation notes were reviewed. An observation noted dated 11/18/24 documented, “…[s/he] has a fist size bruise on [his/her] right elbow area that is dull yellow and maroon in color…[s/he] reports not knowing how [s/he] got it but said it was a few days old.” There was no documented evidence the facility completed an immediate investigation that ruled out abuse or neglect for this injury of unknown cause. During an interview on 01/16/25, Staff 2 (RN) and Staff 6 (RCC) confirmed the injury lacked an investigation to rule out abuse and had not been reported to the local Seniors and People with Disability (SPD) office. The survey team requested the injury be reported, and confirmation was received at 9:30 am on 01/17/25. The need to ensure the facility promptly investigated all injuries of unknown cause to rule out abuse, and reported to the local SPD office when necessary, was discussed with Staff 1 (Administrator) on 01/17/25 at 10:45 am. She acknowledged the findings.

On 1/16/25, Abuse Reporting forms for Resident 1 and Resident 2 were completed for injuries of unknown cause that were discovered during the survey process. Abuse Reporting Forms and chart notes were submitted 1/16/25 to the local SPD office. On 1/30/25 Health Services Director (HSD), RCC, and Administrator reviewed reporting and investigating abuse with RN Consultant Kathleen Elias. On 1/29/25, Abuse reporting reviewed at facility All-Staff Meeting. On 2/6/25, immediate investigation of injuries of unknown cause and reporting abuse to be reviewed with Med Tech and Caregiving staff, including incident report completion, resident interview process, internal notifications, and external notifications. HSD to provide ongoing education to staff at monthly meetings and as needed. The Administrator is responsible to ensure that incidents are investigated timely and any injury of unknown cause is reported to the local SPD office.

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:

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 monitor and document weekly progress for 2 of 3 sampled residents (#s 1 and 2) who experienced a short-term change of condition. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 02/2024 with diagnoses including coronary artery disease, vertigo, and PTSD. The resident’s observation notes dated 10/14/24 through 01/14/25 were reviewed, and interviews with staff were conducted. There was no documented evidence the following changes of condition were monitored with weekly progress noted to resolution: * 11/18/24 – Bruise on right elbow; * 11/19/24 – Three loose teeth; * 11/27/24 – Vertigo and falling into a table; and * 12/22/24 – Right foot pain. During an interview at 10:30 am on 01/16/25, Staff 2 (RN), Staff 3 (RN), and Staff 6 (RCC) confirmed the above changes of condition were not monitored at least weekly to resolution. The need to ensure weekly progress was noted to resolution for short-term changes of condition was discussed with Staff 1 (Administrator) on 01/17/25. She acknowledged the findings. 2. Resident 2 was admitted to the facility in 02/2020, with diagnoses including breast cancer, bilateral hip fractures, and osteoporosis. Review of Resident 2’s observation notes, dated 10/14/24 through 01/14/2025, indicated the resident had experienced the following changes of condition: * 12/05/24- Staff discovered a “thumb-sized bruise” on the resident’s right shin; and * 12/23/24- A bruise was discovered with “blood pooling beneath skin on left wrist”. There was no documented evidence the facility monitored these skin issues at least weekly, through resolution. On 01/16/25 at 2:15 pm, the need to monitor all skin injuries at least weekly, to resolution was discussed with Staff 1 (Administrator) and Staff 2 (RN). They acknowledged the findings.

Health Services Director (HSD) reviewed Change of Condition on 1/30/25 with RN Consultant Kathleen Elias, including protocols and signs that may indicate a short term or significant change of condition. Reviewed need for documentation to reflect monitoring at least weekly to resolution and providing resident-specific directions and suggestions to staff via Interim Service Plans (ISPs). On 2/6/25, Med Tech and Caregiving staff to be educated on identifying changes in the resident’s physical, emotional, and mental functioning and documenting and reporting on changes of condition. HSD to provide ongoing education to staff at monthly meetings and as needed. HSD and RCC will be informed of changes in resident care needs at Stand Up interdisciplinary team meeting Monday through Friday and as needed other times. HSD to enter at least weekly chart note summarizing status and monitoring of Change of Condition to resolution. RN Consultant will be consulted as needed regarding appropriate interventions and strategies of care. Administrator is responsible to ensure that change of condition documentation, evaluation, service planning and monitoring are occuring timely and at appropriate intervals for short- and long-term changes of condition.

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:

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 and accesses were maintained in good repair. Findings include, but are not limited to: The exterior of the facility was toured on 01/14/25 and 01/15/25. The following deficiencies were identified: * Exterior pathways throughout the perimeter of the building contained multiple drop-offs up to four inches, measured from the edge of a concrete sidewalk to the ground. These drop-offs created potential fall hazards for residents; and * Sections of asphalt sidewalk in the rear courtyard, near raised planter beds, were uneven and in need of repair. The uneven sidewalk created a potential fall hazard for residents. On 01/15/24, the building's exterior was toured with Staff 1 (Administrator) and Staff 4 (Facilities Director). They acknowledged the findings.

On 1/29/25 the asphalt sidewalk in the rear courtyard, near raised planter beds, was removed. The ground was leveled and a new concrete pad was poured. On 1/30/25, fill dirt was delivered to the facility to begin filling drop-offs from exterior pathways to the ground. Facilities Director to perform checks of exterior grounds monthly to ensure safe walkways with even surfaces and correct issues as needed. Environmental Rounds program to be created by 2/28/25 with quarterly assignments for departments to review the exterior of building for areas of concern. Findings will be documented and plans for improvement created and carried out by Facilities Director or outside provider, if needed. Administrator to ensure work is performed in a timely manner.

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: