Print Inspection: CHOW002878

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 two unsampled residents were treated with dignity and respect. Findings include, but are not limited to: 1. On 02/24/25 at 2:02 pm, an unsampled resident was observed to exit a public bathroom without clothing or covering on his/her lower half of their body. Another unsampled resident observed the unclothed resident and then ambulated to his/her room. The exposed resident continued to wander through the dining area before s/he entered a room and closed the door. There were no staff available to intervene or ensure the residents dignity while the resident wandered around the dining room without clothes or covering on his/her lower body. 2. On 02/25/25 at 2:28 pm, an unsampled resident was observed to wander into Resident 4’s room wearing a saturated and soiled brief and without appropriate clothing or covering. The unsampled resident was then observed to exit Resident 4’s room and ambulate into a public bathroom. The unsampled resident ambulated with a walker and moved very slowly. Staff 17 (CG) was observed to attempt to re-direct the resident from the public bathroom to his/her room and stated this behavior was “common for this resident.” However, when Staff 17 provided redirection, s/he did not attempt to cover the resident or ensure the resident’s dignity. On 02/25/25 at 4:20 pm, Staff 1 (ED) was informed of both occurrences. The need to ensure residents were treated with dignity and respect was reviewed with Staff 1 and Staff 3 (Health Services Director) on 02/26/25 at 1:56 pm. They acknowledged the findings.

Staff 1, 2, 3, and 4 were immediately educated on resident rights and how to assist residents with maintaining dignity and respect in the event that the resident may expose themselves. As an example, staff should have immediately grabbed a sheet, blanket, throw and covered the resident while they were in the common area. Staff instructed to ensure last rounds are completed and to ensure they know the location of residents, and residents are clean, dry and dressed appropriately. Staff were advised to alert the MT/RN/RCC of any refusals after change of face or reapproaching resident failed. Staff educated at the all staff meeting on 3/10/25 on Resident Rights, specifically dignity and respect. Again staff should have immediately grabbed a sheet, blanket, throw and covered the resident while they were in the common area. Staff instructed to ensure last rounds are completed and residents are clean, dry and dressed appropriately. Reminded staff to alert the MT/RN/RCC of any refusals after change of face or reapproaching resident failed. ARN, RCC, Administrator and Manager on Duty will complete multiple daily walk throughs during the identified times of concern, 2:00-2:30. This will occur daily for 30 days then a minimum of weekly going forward. Administrator will ensure compliance.

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:

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 changes of condition for 3 of 5 sampled residents (#s 3, 4, and 6) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 11/2022 with diagnoses including dementia and depression. The resident’s clinical record, including the current service plan dated 02/16/25, progress notes dated 12/14/24 through 02/16/25, and interim service plans (ISPs) were reviewed. The following was identified: The following changes of condition lacked documentation of resident-specific actions or interventions needed for the resident: * 12/14/24 – Resident to resident altercation; * 01/09/25 – Resident to resident altercation; * 01/10/25 – Resident to resident altercation; and * 01/18/25 – Resident to resident altercation. The need to ensure the facility determined and documented resident-specific actions or interventions needed for changes of condition, was reviewed with Staff 1 (ED) and Staff 3 (Health Services Director) on 02/26/25 at 1:56 pm. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 06/2023 with diagnoses including unspecified dementia with behavior disturbances, history of transient ischemic attacks (TIA), and major depressive disorder. The resident’s clinical record, including the current service plan dated 01/27/25, progress notes dated 12/26/24 through 02/24/25, and interim service plans (ISPs) were reviewed. The following was identified: The following changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident and communicated the determined action or intervention to staff: * 12/28/24 – Unwitnessed fall; * 01/09/25 – New medication; and * 02/09/25 – Unwitnessed fall. The need to ensure the facility determined and documented resident-specific actions or interventions needed for changes of condition and communicated the determined action or intervention was reviewed with Staff 1 (ED) and Staff 3 (Health Services Director) on 02/26/25 at 1:56 pm. They acknowledged the findings. 3. Resident 6 moved into the facility in 08/2024 with diagnoses including dementia. The resident’s current service plan dated 01/29/25 and interim service plans (ISPs) were reviewed. The following was identified: The following changes of condition lacked documentation of resident-specific actions or interventions needed for the resident: * 11/20/24 – Resident to resident altercation; * 01/18/25 – Resident to resident altercation; and * 01/27/25 – Resident to resident altercation. The need to ensure the facility determined and documented resident-specific actions or interventions needed for changes of condition, was reviewed with Staff 1 (ED) and Staff 3 (Health Services Director) on 02/26/25 at 1:56 pm. They acknowledged the findings.

RN and RCC immediately put in place ISP's for resident specific action or interventions for Resident 3, Resident 4, and Resident 6. Going forward the RCC, RN, and Administrator will review ISP interventions daily while in the community for one month for effectiveness and then return to weekly monitoring during our high risk meeting. If interventions are ineffective we'll put forward another intervention/s and monitor for effectiveness. Administrator to ensure compliance.

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 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to coordinate care with outside providers to ensure the continuity of care, for 1 of 3 sampled residents (# 1) who received Home Health nursing services. Findings include, but are not limited to: During the acuity interview, Resident 1 was identified to receive home health nursing services. 02/24/25 at 1:25 pm, the resident was observed lying in bed with a partial dressing on the right lower leg. The resident stated s/he had a bandage on his/her leg. Resident 1’s clinical records, including recommendations, revealed the following: * 01/17/25 - “okay to wash in shower no scrubbing, gentle soap, allow to dry or pat w/gauze [with gauze] gently. Cover w/non adherent dressing or abd & wrap w/ace or rolled gauze to protect”; * 01/21/25 - “Wound care daily – cleanse with NS [normal saline] or wound cleanser put drg [dressing] with gauze, cover with non adherent drsg [dressing] secured with rolled gauze and tape.”; * 01/22/25 – “Please assist & encourage [the resident to] walk to dine for meals with [a] walker for support.”; and * 02/04/25 – “please continue to change drsg [dressing] daily as ordered.” There was no documented evidence that these recommendations were communicated to the staff for coordination of care related to outside healthcare services. On 02/26/25 at 1:00 pm, the above findings were shared with Staff 1 (ED) and Staff 3 (Health Service Director, RN) and the need to ensure ongoing coordination of care with outside provider services was discussed. Staff acknowledged the findings.

Administrator educated RN as well as RCC regarding the need to complete an ISP for recommendations provided by Outside Providers. ISP will be immediately generated by RN or RCC to ensure continuity of care, specifically communicating to staff changes to the resident's care and/or new orders/recommendations. RN immediately completed ISP for Resident 1. RN, RCC, and Administrator will review Outside Provider notes & ISP's daily while in the building for one month then return to weekly monitoring. Administrator will ensure compliance.

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. 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 physician orders were carried out as prescribed for 1 of 4 sampled residents (# 1) whose orders were reviewed. Findings include, but are not limited to: Resident 1 was admitted to the facility in 07/2022 with diagnoses including dementia. Resident 1 had physician orders, dated 12/08/24, to administer Milk of Magnesia 30 ml by mouth “as needed of no BM [bowel movement] after 1 day” and the 02/14/25 order indicated “Constipation – Track BM [bowel movement] so you can give milk of mag [magnesia] and Miralex as ordered.” The resident’s bowel track records were reviewed, which indicated the resident experienced no bowel movement from 02/09/25 through 02/12/25 for four days and again from 02/18/25 to 02/20/25 for three days. The resident’s Observation note indicated on 02/12/25, the resident “was very constipated, took milk of mag [Magnesia].” On 02/13/25, staff documented the resident was very anxious, sitting on the toilet for 40 minutes and “was trying to dig [his/her] bowel movement out with [his/her] fingers…finally got [his/her] bowel movement out…” The 02/01/25 through 02/24/25 MAR was reviewed and showed the administration of Milk of Magnesia on 02/12/25, four days after the resident’s last bowel movement. It was also noted that when Milk of Magnesia was administered on 02/20/25, the resident had not had a bowel movement for three days. This indicated the facility failed to carry out the physician’s orders as prescribed. On 02/26/25 at 1:00 pm, the physician orders, bowel records, observation notes and MARs were reviewed with Staff 1 (ED) and Staff 3 (Health Services Director, RN). The need to ensure orders were carried out as prescribed was discussed, and Staff 1 and Staff 3 acknowledged the findings.

Administrator instructed RN and RCC to request provider discontinue current MOM order and request routine bowel care order for Resident 1. Administrator discussed with RN and RCC the importance of reviewing medicaiton orders accuratley and thoroughly, flagging or hi-lighting any unusual orders and requesting clarification. RN educated Med Tech's at the monthly Med Tech meeting, 3/10/25 of the importance of reviewing orders for accuracy when they are approving new orders, as well as the need to ensure orders are followed as prescribed by the provider. Med Tech's were reminded they are the "first check" for accuracy when approving medication. Administrator will review orders while in community for 30 days and then weekly going forward. Administrator will ensure compliance.

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 411-054-0090 (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 ensure residents were instructed on fire and life safety procedures within 24 hours of admission and re-instructed, at least annually. Findings include, but are not limited to: Fire and life safety records were requested and reviewed with Staff 1 (ED) on 02/25/25 and the following were identified: * There was no documented evidence of instruction to residents on general safety procedures, evacuation methods, responsibilities during a fire within 24 hours of admission and re-instruction to residents at least annually. On 02/25/25 at 1:50 pm, Staff 1 reported since the facility changed ownership in February of last year, the system was discontinued. As a result, there was no documented evidence of instruction to residents on general safety procedures. The need to ensure residents received fire and life safety training within 24 hours of admission and at least annually was discussed with Staff 1 on 02/25/25 at 3:15 pm. She acknowledged the findings.

Administrator immediately implemented the Emergency Disaster Orientation for current residents. Administrator has added the training to the Move-In packet for new move-ins and added to the annual training calendar. Administrator will audit new move-in paper work weekly for one month to include the Emergency Disater Orientation and then monthly going forward. Administrator will ensure compliance.

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:

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure two unsampled residents were treated with dignity and respect. Findings include, but are not limited to: Refer to C 200.

Staff 1, 2, 3, and 4 were immediately educated on resident rights and how to assist residents with maintaining dignity and respect in the event that the resident may expose themselves. As an example, staff should have immediately grabbed a sheet, blanket, throw and covered the resident while they were in the common area. Staff instructed to ensure last rounds are completed and to ensure they know the location of residents, and residents are clean, dry and dressed appropriately. Staff were advised to alert the MT/RN/RCC of any refusals after change of face or reapproaching resident failed. Staff educated at the all staff meeting on 3/10/25 on Resident Rights, specifically dignity and respect. Again staff should have immediately grabbed a sheet, blanket, throw and covered the resident while they were in the common area. Staff instructed to ensure last rounds are completed and residents are clean, dry and dressed appropriately. Reminded staff to alert the MT/RN/RCC of any refusals after change of face or reapproaching resident failed. ARN, RCC, Administrator and Manager on Duty will complete multiple daily walk throughs during the identified times of concern, 2:00-2:30. This will occur daily while in the building for 30 days then a minimum of weekly going forward. Administrator will ensure compliance.

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure two unsampled residents were treated with dignity and respect. Findings include, but are not limited to: Refer to C 200.

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. This Rule is not met as evidenced by:

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are limited to: Refer to C200 and C422.

Staff 1, 2, 3, and 4 were immediately educated on resident rights and how to assist residents with maintaining dignity and respect in the event that the resident may expose themselves. As an example, staff should have immediately grabbed a sheet, blanket, throw and covered the resident while they were in the common area. Staff instructed to ensure last rounds are completed and to ensure they know the location of residents, and residents are clean, dry and dressed appropriately. Staff were advised to alert the MT/RN/RCC of any refusals after change of face or reapproaching resident failed. Staff educated at the all staff meeting on 3/10/25 on Resident Rights, specifically dignity and respect. Again staff should have immediately grabbed a sheet, blanket, throw and covered the resident while they were in the common area. Staff instructed to ensure last rounds are completed and residents are clean, dry and dressed appropriately. Reminded staff to alert the MT/RN/RCC of any refusals after change of face or reapproaching resident failed. ARN, RCC, Administrator and Manager on Duty will complete multiple daily walk throughs during the identified times of concern, 2:00-2:30. This will occur daily while in the building for 30 days then a minimum of weekly going forward. Administrator will ensure compliance. Administrator immediately implemented the Emergency Disaster Orientation for current residents. Administrator has added the training to the Move-In packet for new move-ins and added to the annual training calendar. Administrator will audit new move-in paper work weekly for one month to include the Emergency Disater Orientation and then monthly going forward. Administrator will ensure compliance.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by:

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure health service were consistently provided. Findings include, but are not limited to: Refer to C270, C290 and C303.

RN and RCC immediately put in place ISP's for resident specific action or interventions for Resident 3, Resident 4, and Resident 6. Going forward the RCC, RN, and Administrator will review ISP interventions daily for one month for effectiveness and then return to weekly monitoring during our high risk meeting. If interventions are ineffective we'll put forward another intervention/s and monitor for effectiveness. Administrator to ensure compliance. Administrator educated RN as well as RCC regarding the need to complete an ISP for recommendations provided by Outside Providers. ISP will be immediately generated by RN or RCC to ensure continuity of care, specifically communicating to staff changes to the resident's care and/or new orders/recommendations. RN immediately completed ISP for Resident 1. RN, RCC, and Administrator will review Outside Provider notes & ISP's daily for one month then return to weekly monitoring. Administrator will ensure compliance Administrator instructed RN and RCC to request provider discontinue current MOM order and request routine bowel care order for Resident 1. Administrator discussed with RN and RCC the importance of reviewing medicaiton orders accuratley and thoroughly, flagging or hi-lighting any unusual orders and requesting clarification. RN educated Med Tech's at the monthly Med Tech meeting, 3/10/25 of the importance of reviewing orders for accuracy when they are approving new orders, as well as the need to ensure orders are followed as prescribed by the provider. Med Tech's were reminded they are the "first check" for accuracy when approving medication. Administrator will review orders while in community for 30 days and then weekly going forward. Administrator will ensure compliance.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by:

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to develop individualized activity plans based on evaluations that were reflective of residents' current preferences and needs for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose records were reviewed. Findings include, but are not limited to: Resident 1, 2, 3 and 4’s service plans and evaluations were reviewed during the survey. The records lacked individualized plans for meaningful activities that promoted the physical and emotional well-being of each resident, and failed to address one or more of the following required elements: * Past and current interests; * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Activities for behavior interventions. On 02/26/25, the lack of individualized activity plans that were reflective of each resident’s current status, and addressed all required components was discussed with Staff 1 (ED) and Staff 3 (Health Services Director, RN). They acknowledged the findings.

LEC immediately updated areas of concern in the service plan to reflect the residents individual preferences for Resident 1, 2, 3 and 4. RN, RCC and LEC will ensure to document in residents individual service plans for meaningful activities that promote the physical and emotional well-being of each resident at initial assessment, 30 day assessment, 60 day assessment, quarterly assessment and COC. LEC will ensure individual plans that meet the individual residents needs and update as needed. If the individual activity plan does not reflect the resident's current status accurately, the LEC will update the resident's service plan. RCC and Administrator will monitor the residents individualized activity plans monthly per service plan calendar. Administrator will ensure compliance.

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: