Print Inspection: CHOW000069

OAR 411-054-0034 (1-6) Resident Move-in and Eval: 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 include the following information: (A) Prior living arrangements; (B) Emergency contacts; (C) Service plan involvement - resident, family, and social supports; (D) Financial and other legal relationships, if applicable, including, but not limited to:(i) Advance directives;(ii) Guardianship;(iii) Conservatorship; and(iv) Power of Attorney. (E) Primary language; (F) Community connections; and (G) 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) 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).(b) 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.(c) 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.(d) Cognition, including:(A) Memory;(B) Orientation;(C) Confusion; and(D) Decision-making abilities.(e) Personality, including how the person copes with change or challenging situations.(f) Communication and sensory abilities including:(A) Hearing;(B) Vision;(C) Speech;(D) Use of assistive devices; and(E) Ability to understand and be understood.(g) 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.(h) Independent activities of daily living including:(A) Ability to manage medications;(B) Ability to use call system;(C) Housework and laundry; and(D) Transportation.(i) Pain pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort.(j) Skin condition.(k) Nutrition habits, fluid preferences, and weight if indicated.(l) List of treatments type, frequency, and level of assistance needed.(m) Indicators of nursing needs, including potential for delegated nursing tasks.(n) 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.(o) 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. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the resident’s initial evaluation addressed all required elements, for 1 of 1 sampled resident (#4) whose initial evaluation was reviewed. Findings include, but are not limited to: Resident 4 was admitted to the facility in 08/2024 with diagnoses including hypertension and hypothyroidism. The resident’s initial evaluation lacked information regarding the following required elements: * Customary routines: sleeping, eating, bathing; * Non-drug interventions for mental health issues; * Dental status; * Pharmacological and non-pharmacological interventions for pain; * Emergency evacuation ability; and * Complex medication regimen. The missing elements were reviewed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (Wellness Director), Staff 5 (RCC) and Staff 10 (Regional Wellness Director) on 08/28/24. They acknowledged the findings.

1. Facility has updated growth and wellness plan for Resident #4 to include missing information as indicated by SOD. 2. Policy training will be conducted with RNs and Administrator on 9.20.24. RN to complete initial evaluation. Administrator to complete secondary review to ensure that all required elements are captured. Facility has updated move-in evaluation form to include missing information as indicated by SOD. 3. System will be reviewed with each new move-in and at monthly CQI Meetings. 4. Administrator or designee will be responsible to ensure all elements of move-in evaluations are complete.

OAR 411-054-0034 (1-6) Resident Move-in and Eval: 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 include the following information: (A) Prior living arrangements; (B) Emergency contacts; (C) Service plan involvement - resident, family, and social supports; (D) Financial and other legal relationships, if applicable, including, but not limited to:(i) Advance directives;(ii) Guardianship;(iii) Conservatorship; and(iv) Power of Attorney. (E) Primary language; (F) Community connections; and (G) 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) 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).(b) 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.(c) 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.(d) Cognition, including:(A) Memory;(B) Orientation;(C) Confusion; and(D) Decision-making abilities.(e) Personality, including how the person copes with change or challenging situations.(f) Communication and sensory abilities including:(A) Hearing;(B) Vision;(C) Speech;(D) Use of assistive devices; and(E) Ability to understand and be understood.(g) 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.(h) Independent activities of daily living including:(A) Ability to manage medications;(B) Ability to use call system;(C) Housework and laundry; and(D) Transportation.(i) Pain pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort.(j) Skin condition.(k) Nutrition habits, fluid preferences, and weight if indicated.(l) List of treatments type, frequency, and level of assistance needed.(m) Indicators of nursing needs, including potential for delegated nursing tasks.(n) 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.(o) 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. 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 observation, interview, and record review, it was determined the facility failed to determine and document what actions or interventions were needed for short term changes of condition, communicate actions and/or interventions to staff on each shift, and monitor the change of condition at least weekly until resolved for 3 of 3 sampled residents (#s 1, 2 and 3) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 06/2024 with diagnoses including left hip fracture and cerebrovascular accident. The current service plan dated 07/22/24, Temporary Service Plans (TSPs), outside provider notes, and progress notes dated 06/18/24 through 08/26/24 were reviewed. Observations and interviews with resident and staff were completed between 08/26/24 and 08/28/24. The facility failed to determine what action or intervention was needed for the resident, communicate the action or intervention to staff on each shift, and/or document weekly progress until the condition resolved for the following conditions: * 06/18/24 – New admission to facility; * 06/18/24 – Redness/rash to buttocks; * 07/17/24 – New medications; * 07/20/24 – Admission to hospice services; * 07/22/24 – Skin tear to right arm; * 07/30/24 – Redness with open areas on buttocks; * 08/01/24 – New medication; * 08/04/24 – Left wrist pain/swelling; * 08/07/24 – New medication and medication change; and * 08/20/24 – Medication change. The need to ensure the facility determined and documented what action or interventions were needed for changes of condition, the interventions were communicated to staff on all shifts, and were monitored at least weekly through resolution was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 5 (RCC) and Staff 10 (Regional Wellness Director) on 08/28/24. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 06/2022 with diagnoses including neurogenic bladder, gastroesophageal reflux disease (GERD) and chronic pain. The resident was fully able to manage his/her health care needs. The resident’s record, including the last 90 days of progress notes, the most recent evaluation and service plan and Temporary Service Plans (TSPs), was reviewed during the survey. The following issues were identified: a. On 06/09/24, the resident notified a MT of a bump on his/her nose. The facility RN evaluated the condition and notified the physician, who referred the resident to an oncologist. The facility RN documented monitoring of the condition weekly until 06/26/24. The next and final note in the record was then written on 07/24/24 where the RN documented there was some redness, and he had not received lab results from the resident’s biopsy. There were no additional noted indicating the status of the condition and whether it was determined to be resolved. b. On 08/02/24, the resident’s right eye was identified to be puffy with discharge. The resident was diagnosed with conjunctivitis and prescribed eye drops, which s/he was able to self-administer. The facility documented monitoring of the condition on 08/05/24 and 08/16/24. The facility failed to document monitoring of the condition at least weekly and did not document whether the condition was determined to be resolved. The need to ensure the facility had a system for documenting monitoring of short-term changes of condition at least weekly until resolved was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (Wellness Director), Staff 5 (RCC) and Staff 10 (Regional Wellness Director) on 08/28/24. They acknowledged the findings. 3. Resident 2 was admitted to the facility in 10/2020 with diagnoses including Alzheimer’s Disease, atrial fibrillation, and depression. In an acuity interview with Staff 6 (MT) and Staff 7 (MT) on 08/26/24, Resident 2 was identified as a high fall risk who had experienced recent falls. Review of the resident’s service plan, dated 07/20/24, progress notes, dated 05/26/24 through 08/26/24, Temporary Service Plans (TSPs) and incident reports indicated the resident had experienced six falls in the previous 90 days. The facility failed to determine and document what actions or interventions were needed for the resident in response to the series of documented falls, as evidenced by the following: In the last ninety days, there was one TSP, dated 07/30/24, which simply stated “Fall-no injuries”. There were no new interventions provided, and no instructions for staff. Though the facility completed an incident report following each fall, which summarized what had happened, there was no documented evidence new interventions were developed, or the existing interventions were evaluated for effectiveness in preventing further falls. On 08/29/24, the need to ensure interventions were developed in response to changes of condition, conveyed to staff on all shifts, and monitored for effectiveness was discussed with Staff 1 (Administrator), Staff 2 (Registered Nurse), Staff 5 (Resident Care Coordinator), and Staff 10 (regional Wellness Director). They acknowledged the findings.

1. Change of condition plan for resident #1 including Hospice support, related elements and interventions has been implemented and will be monitored and resolved through daily clinical meetings to include TSP and IR review. Change of condition plan for Resident #2 including related interventions, PT support, and two weeks of heart monitoring to rule out issues other than afib has been implemented and will be monitored and resolved though review of TSPs and IRs at daily clinical meetings. Resident #3 no longer resides in the facility effective 09.24.24. 2. a. Change of Condition class through Oregon Care Partners to be taken by RNs and Administrator by 10.15.24. b. Moving forward, the system will be to review potential COCs and incident reports in daily clinical meetings 3-4 days a week starting 9.23.24 with RNs and Administrator as available. Alert charting and resolution of temporary COCs will be addressed and managed at daily clinical meetings. c. RNs will be responsible for resolving COCs. d. Staff training regarding incident reports, alert charting and TSPs with interventions to be conducted by RN and Administrator on 9.27.24. Ongoing staff training on Alert Charting, TSPs and IRs to be conducted quarterly at monthly staff meetings. 3. COCs will be monitored for TSPs and resolutions weekly x4 weeks, and then monthly at CQI meetings. 4. Administrator and RNs will monitor system to ensure that TSPs are initiated and resolutions are timely. BOM will monitor 10.15.24 completion of Oregon Care Partners class.

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 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed and written, signed physician or other legally recognized practitioner orders were documented in the facility record for all medications and treatments the facility was responsible to administer, for 2 of 4 sampled residents (#s 3 and 4) whose orders and MAR were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 06/2022 with diagnoses including neurogenic bladder, gastroesophageal reflux disease (GERD) and chronic pain. Review of the resident’s most recent signed list of physician orders and the 08/01/24 through 08/25/24 MAR indicated the following: * The MAR indicated the facility had been administering Resident 3 sennosides (for constipation) 8.6 mg oral tablet – 1 tablet twice daily without a signed physician order in the resident’s record. * The MAR indicated the facility had been administering Resident 3 polyethylene glycol 3350 oral powder (for constipation) – 1 glass every other day without a signed physician order in the resident’s record. The current order was for the medication to be administered daily. The need to ensure written, signed physician orders were documented in the facility record was reviewed with Staff 3 (Wellness Director) and Staff 5 (RCC) on 08/27/24 and with Staff 1 (Administrator), Staff 2 (RN), Staff 3, Staff 5 and Staff 10 (Regional Wellness Director) on 08/28/24. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 08/2024 with diagnoses including hypertension and hypothyroidism. Review of the resident’s most recent signed list of physician orders and the 08/01/24 through 08/25/24 MAR indicated the following deficiencies: * Resident 4 had signed Physician orders to “Notify PCP [primary care physician] if systolic blood pressure [BP] is greater than 180 or less than 100 or the diastolic BP is greater than 90 or less than 40 unless otherwise specified.” The resident’s BP was outside these parameters three times between 08/23/24 and 08/27/24, and there was no documented evidence the facility notified the physician as ordered. * Resident 4 had signed Physician orders to “Notify PCP [primary care physician] of pulse greater than 100 or less than 50 unless otherwise specified.” There was no documented evidence the facility was obtaining the resident’s pulse as ordered. The need to ensure medication and treatment orders were carried out as prescribed was reviewed with Staff 3 (Wellness Director) and Staff 5 (RCC) on 08/27/24 and with Staff 1 (Administrator), Staff 2 (RN), Staff 3, Staff 5 and Staff 10 (Regional Wellness Director) on 08/28/24. They acknowledged the findings.

1. Medication Treatment orders for Residents #3&4 have been reviewed and updated. Treatment orders for resident #4 requiring notification of PCP when abnormal parameters exist have been reviewed and corrected by RN with necessary guidance from PCPs. 2. Audit of all resident treatment orders and treatment orders with parameters requiring PCP notification has been completed by RN with necessary updates and corrections. RN to complete final check on all new treatment orders to ensure parameters are clear and to ensure that reason for use and PCP notification are entered and accurate with each medication. RN and Administrator to train staff on the process to notify PCP via fax on abnormal vs normal parameters on 9.27.24. 3. MAR audit of each new order with parameters and notification of PCPs to be monitored weekly x4 then Monthly. 4. RN and Resident Care Coordinator to be responsible for monthly audits.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by:

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 maintain an accurate MAR for all medications that were ordered by a legally recognized prescriber and are administered by the facility, for 2 of 4 sampled residents (#s 3 and 4) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 06/2022 with diagnoses including neurogenic bladder, gastroesophageal reflux disease (GERD) and chronic pain. Review of the resident’s most recent signed list of physician orders and the 08/01/24 through 08/25/24 MAR indicated the following deficiencies: * The order to administer simethicone (for severe gas) 80 mg tablet – 1 tablet TID was transcribed incorrectly on the MAR as 125 mg tablet – 1 tablet 4 times daily as needed. * The order to administer simethicone 125 mg tablet – 1 tablet daily as needed, may have one additional tablet daily as needed for a total of 4 doses was transcribed incorrectly on the MAR as 125 mg tablet – 1 tablet four times daily as needed. * The order to administer sennosides (for constipation) 8.6 mg tablet – take 2 tablets daily as needed was incorrectly transcribed to the MAR as 1 tablet twice daily and the dosage was not included. * The MAR included instructions to administer hydroxyzine (for anxiety) 25 mg capsule – 1 capsule daily as needed but there was no written, signed order in the resident’s record. * When transcribed to the MAR, the order for omeprazole (to treat GERD) 20 mg capsule – 1 capsule daily, lacked the dosage. * The resident was prescribed atenolol (to treat high blood pressure) 25 mg tablets – 1 tablet orally every morning. The MAR lacked medication-specific instructions for when to hold the medication or when to call the prescriber or nurse. The need to ensure physician orders were transcribed to the MAR accurately and medications included parameters when applicable was reviewed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (Wellness Director), Staff 5 (RCC) and Staff 10 (Regional Wellness Director) on 08/28/24. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 08/2024 with diagnoses including hypertension and hypothyroidism. Review of the resident’s most recent signed list of physician orders and the 08/01/24 through 08/25/24 MAR indicated the following deficiencies: * The resident was prescribed clonidine HCL (to treat high blood pressure) 0.1 mg tablets – 1 tablet orally once daily. The MAR lacked medication-specific instructions for when to hold the medication or when to call the prescriber or nurse. The need to ensure medications included parameters when applicable was reviewed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (Wellness Director), Staff 5 (RCC) and Staff 10 (Regional Wellness Director) on 08/28/24. They acknowledged the findings.

1. Resident #3's medication list has been audited and updated to ensure that are physician orders are accurately and completely transcribed to the MAR with applicable perameters. Resident #4's medication list has been audited and updated to include all applicable perameters. Resident #3 has moved out of the facility effective 9.24.24. 2. Full audit of all resident med lists has been completed to ensure that each physician's order is transcribed completely and correctly including dosage, administration times, resident specific instructions and resident specific perameters. Moving forward, the system will be a three person check, with RN to complete final check of all new physician's orders to ensure accuracy and to ensure that dosage, time of administration, resident specific interventions and perameters are clearly transcribed. Staff training on MAR accuracy and the rights of medication administration to be conducted by RN and Administrator at 9.27.24 med tech meeting and then quarterly at monthly med tech meetings. 3. Med list audit of each new order to be conducted weekly x4 then monthly x3 then quarterly thereafter. Continued staff training on correct medication administration to be conducted quarterly at monthly med tech meetings. 4. RNs to be responsible that audits are completed.

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:

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications were administered only after documented, resident specific non-pharmacological interventions were tried with ineffective results for 1 of 1 sampled resident (#1) who had an order for PRN psychotropic medications. Findings include, but are not limited to: Resident 1 was admitted to the facility in 06/2024 with diagnoses including left hip fracture and cerebrovascular accident. The resident's 08/01/24 to 08/26/24 MAR, progress notes and current physician orders were reviewed. The following was identified: * The resident had an order for haloperidol lactate, administer one ml by mouth every two hours as needed for agitation/nausea/vomiting. The MAR indicated staff administered the PRN medication on four occasions from 08/05/24 to 08/08/24. There was no documented evidence staff attempted non-drug interventions with ineffective results prior to administering the PRN psychotropic medication. * The resident had an order for lorazepam, administer one tablet by mouth every two hours as needed for anxiety. The MAR indicated staff administered the PRN medication on eight occasions from 08/04/24 to 08/19/24. There was no documented evidence staff attempted non-drug interventions with ineffective results prior to administering the PRN psychotropic medication. The need to ensure there was documentation that staff administered PRN psychotropic medications only after attempting resident specific non-pharmacological interventions with ineffective results was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 5 (Resident Care Coordinator) and Staff 10 (Regional Wellness Director) at 3:30 pm on 08/28/24. They acknowledged the findings.

1. Resident #1's PRN halperidol order for nausea, vomiting and agitation has been updated with resident specific non drug interventions and individually recognized behaviors. Resident #1's lorazepam order for anxiety has been updated with resident specific non drug interventions and individually recognized behaviors. 2. Audit of all PRN psychotropic meds for all residents has been completed by RN to ensure that all person centered individualized non drug interventions and individually recognized behaviors are written into orders. Staff training to focus on recognition of resident behaviors and understanding of person-centered non-medication inteventions to be conducted on 9.27.24. Staff training to focus on personlized behavior recognition and proper documentation of resident specific ineffective non drug interventions prior to PRN psychotropic med administration to be conducted by RN and Administrator on 9.27.24. 3. With full audit completed, moving forward, all psychotropic medications to be reviewed monthly with CQI meetings and quarterly pharmacy review to ensure that interventions are in place, accurate and up to date. Staff training on PRN psychotropics and related elements to be led by RN and Administrator on 9.27.24. Continued staff training on PRN psychotropics and related elements to be conducted quarterly at monthly med tech meeting. 4. RNs and Administrator responsible for monthy audits.

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by:

OAR 411-054-0070 (2) Staffing Rqmt and Training: Training Rqmts (2) REQUIREMENTS APPLICABLE TO ALL TRAINING. The facility shall:(a) Have a training program that includes methods to determine competency of direct care staff through evaluation, observation, or written testing. Facility shall also maintain documentation regarding each direct care staff ' s demonstrated competency.(b) Maintain written documentation of all trainings completed by each employees. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have a training program that included methods to determine competency of direct care staff through evaluation, observation, or written testing and maintain documentation regarding each direct care staff’s demonstrated competency. Findings include, but are not limited to: Training records were reviewed on 08/27/24 with Staff 1 (Administrator). Competency determinations for two sampled direct care staff were requested. Staff 1 stated the facility did not document competency reviews for direct care staff in the facility. The need to ensure the facility had a training program that included methods to determine competency of direct care staff and that each direct care staff’s demonstrated competency was documented, was reviewed with Staff 1, Staff 2 (RN), Staff 3 (Wellness Director), Staff 5 (RCC) and Staff 10 (Regional Wellness Director) on 08/28/24. They acknowledged the lack of a process for determining and documenting competency of direct care staff.

1. Demonstrated competency evaluation and checklist has been completed with identified staff. Full audit to be conducted by 10.15.24 to identify any missing pre-service training or demonstrated competency evaluations. Pre-service training and/or competency evaluations to be completed by all staff no later than 10.28.24. 2. System correction going forward: Staff will not begin floor training until all pre-service training is completed. PCAs will not be placed on the floor independently until competency evaluation is completed. 3. Training system will be evaluated quarterly at CQI meetings with tracking completed by the BOM. 4. Administrator and RCC to be responsible for ensuring that team members do not work independently without required training. BOM will be responsible to track pre-service and annual training.

OAR 411-054-0070 (2) Staffing Rqmt and Training: Training Rqmts (2) REQUIREMENTS APPLICABLE TO ALL TRAINING. The facility shall:(a) Have a training program that includes methods to determine competency of direct care staff through evaluation, observation, or written testing. Facility shall also maintain documentation regarding each direct care staff ' s demonstrated competency.(b) Maintain written documentation of all trainings completed by each employees. This Rule is not met as evidenced by:

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to provide and maintain a written record of fire safety instruction to residents, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. Findings include, but are not limited to: Review of facility records on 08/27/24 identified the following: There was no documented evidence annual training on fire safety was provided to residents. On 08/28/24 the need to provide and document fire safety instruction to residents, at least annually, in accordance with the OFC was discussed with Staff 1 (Administrator) and Staff 4 (Maintenance Director). They acknowledged the findings.

1. Annual Fire and Life Safety Training for Residents will be provided for all residents by 10.28.24. 2. Fire and Life Safety Training will be provided within 24 hours of move-in. Annual training will be provided in co-ordination with 90 evaluations. 3. Resident training will be monitored quarterly at CQI meetings. 4. Maintenance director to work with clinical team to provide trainings.

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

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (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 the 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. A RCF 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 will 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 materials and surfaces clean and in good repair. Findings include, but are not limited to: The interior of the facility was toured on 08/26/24 at approximately 3:30 pm. The following were identified: * Scrapes and gouges on wall and baseboard in dining room; * Dark marks and scratches on wood doors and door jambs of multiple resident apartments; * Scrapes and damage on wood book shelf, bench and furniture in common hallways; * Black scrapes on metal exit doors, leading to outdoor areas; * Many chairs in dining room had stained discolored seats; * Scuffs and damage to upright square pillar in dining room; * Apartment 133 had two dark stains on carpet; and * Dark stain on the carpet in the hallway near apartment 118. On 08/27/24, the interior areas were reviewed with Staff 1 (Administrator) and Staff 4 (Maintenance Director). They acknowledged the findings.

1. Facility will attempt to clean dark marks from walls, baseboards and doors, with a painting plan to be completed by 10.28.24 to address what could not be cleaned off. Facility to contact carpet cleaning vendor to address the stains in #133 and near #118. Bids to be obtained for replacement of stained and gouged dining chairs; bid will be obtained to repair baseboard, wall and pillar damage in the dining room; bid will be obtained to replace damaged bookshelf and furniture. 2. Cleaning of baseboards and doors will be placed onto the task list for the housekeeping team. Monthly walk-throughs will be completed to ensure all areas of the community are in good repair. 3. Weekly walk-throughs x4 then monthly walk-throughs to be completed and results brought to CQI meetings with any issues being addressed as they arise. 4. Maintenance director will monitor the building and the Administrator will follow up to ensure completion.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (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 the 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. A RCF 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 will be kept clean and in good repair. This Rule is not met as evidenced by: