Print Inspection: CHOW006251

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure injuries of unknown cause were reported to the local Seniors and People with Disability (SPD) office as suspected abuse, unless an immediate facility investigation reasonably concluded and documented the injury was not the result of abuse for 2 of 2 sampled residents (#s 1 and 2) whose incidents were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 2021 with diagnoses including dementia. Resident 1’s service plan, dated 07/17/25, noted the resident was dependent on staff for ADL care and was identified to be at risk for falls. Progress notes reviewed between 06/05/25 through 08/26/25 noted the following: * 06/19/25 - “…resident had a quarter sized bruise on the back of [his/her] upper thigh.” On 08/27/25 at 9:16 am, an interview with the resident was attempted. Resident 1 “was not able to respond to surveyor questions.” There was no documented evidence of an investigation of the injury of unknown cause to rule out abuse. The facility was instructed to report the injury of unknown cause to the local SPD office. Investigation of the injury of unknown cause was completed on 08/28/25 at request of the surveyor. The completed investigation reasonably ruled out abuse. The need to ensure all injuries of unknown cause were reported to the local SPD office as suspected abuse, unless an immediate facility investigation reasonably concluded and documented the physical injury was not the result of abuse, was discussed with Staff 1 (ED) and Staff 2 (MC Wellness Manager/LPN) on 08/28/25 at 3:12 pm. Staff acknowledged the findings. 2. Resident 2 moved into the community in 10/2021 with diagnoses including dementia and hypothyroidism. The resident’s 06/03/25 through 08/27/25 progress notes and incident reports were reviewed. The following was identified: A 08/06/25 progress note documented, “Quarter-sized bruise to right forearm is noted. It is dark purple on the outside with a reddened center.” There was no documented evidence that the injury of unknown cause was immediately investigated to rule out abuse. During an interview at 11:20 am on 08/28/25, Staff 2 (MC Wellness Manager/LPN) confirmed the above injury lacked an investigation and had not been reported to the local Seniors and People with Disabilities (SPD) office. The surveyor requested the above injury be reported to the local SPD office, and confirmation was received at 12:20 pm on 08/28/25. The need to report injuries of unknown cause to the local SPD office unless an immediate investigation reasonably ruled out abuse was discussed with Staff 1 (ED), Staff 2, Staff 13 (Regional RN), and Witness 1 (Nurse Consultant) on 08/28/25. They acknowledged the findings.

1. LN investigated the incident that occurred and reported the injury of unknown origin to APS as directed. 2. ED/LN will review and investigate all incidents within 24 hours and if unable to definitively rule out abuse will report to APS immediately. 3. Daily review of all incidents, alert charting, and 24 hour log to investigate all incidents. Weekly evaluation once weekly to ensure correction is maintained. 4. LN/ED will be responsible to see that corrections are completed and monitored.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by:

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure short-term changes of condition had documented weekly progress noted to resolution for 1 of 2 sampled residents (#1) who experienced changes of condition. Findings include, but are not limited to: Resident 1 was admitted to the facility in 2021 with diagnoses including dementia. Resident 1’s service plan, dated 07/17/25, noted the resident was dependent on staff for ADL care, received hospice services, and was identified to be at risk for falls. Progress notes reviewed between 06/05/25 through 08/26/25 noted multiple short-term changes of condition in the following areas: * Non-injury falls; * Puking episode; * Severe diarrhea; and * Seizure episode. Although the changes of condition were identified and monitoring was initiated, there was no documented evidence of progress noted to resolution. Resident 1 was observed throughout the survey to ambulate independently throughout the unit and received feeding cueing/prompting from staff. Changes of condition with subsequent monitoring through resolution was discussed with Staff 1 (ED) and Staff 2 (MC Wellness Manager/LPN) on 08/28/25 at 3:12 pm. No additional information was provided.

1. LN resolved the short term change of condition. 2. Review of 24 hour log, interim service plans, and alert charting 5 days a week and LN/ED will address all areas of short term change of condition when resolving the change. 3. This area will be reviewed 5 days a week and then evaluated once a week to ensure compliance is maintained. 4. LN/ED will be responsible to see that the corrections are completed and monitored.

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 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment related to incontinence care for 2 of 2 sampled residents (#s 1 and 2) whose care was observed. Findings include but are not limited to: During the survey, bladder and bowel incontinence care was observed being provided to Residents 1 and 2. During both observations, staff were observed not to change gloves after providing perineal care and before touching clean briefs, clothing, and furniture. The need to ensure staff consistently used universal precautions was discussed with Staff 1 (ED), Staff 2 (MC Wellness Manager/LPN), Staff 13 (Regional RN), and Witness 1 (Nurse Consultant) on 08/28/25. They acknowledged the findings.

1. Memory Care staff received reeducation and observation for understanding universal percautions and infection control, especially related to toileting and peri-care. 2. Ongoing training and observation for proper infection control when providing assitance with ADLs. Quarterly follow up with skills observations for care staff to ensure ongoing understanding and compliance. 3. Random observations to occur with each care partner at least once weekly to ensure compliance and then ongoing quarterly skills observations to ensure maintained compliance. 4. ED/LN/RCS provided reeducation and training to all MC care partners and monitored weekly until compliance achieved and quarterly to monitor ongoing.

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by:

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure residents were allowed privacy in their own units, related to propping residents’ doors open. Findings include, but are not limited to: During the survey, multiple doors to resident apartments throughout the memory care community were noted to be propped open with door stoppers, including Residents’ 1 and 2. In an interview on 08/28/25, Staff 2 (MC Wellness Manager/LPN) reported that doors were propped open for safety measures specific to falls that residents had experienced. She acknowledged that Residents 1 and 2 were unable to consent to this and that propping the doors open had not been discussed with the residents’ powers of attorney. On 08/28/25, the need to ensure residents were allowed privacy in their own units was discussed with Staff 1 (ED), Staff 2, Staff 13 (Regional RN), and Witness 1 (Nurse Consultant). They acknowledged the findings.

1. Both resident 1 and 2 were asked preference of door open or closed and were unable to confirm wishes so family was contacted and silent bed alarms were placed for additional resident fall safety behind closed doors. Interim service plans were put in place for staff to close doors and provide frequent safety checks until silent alarms in place. 2. Periodic review of resident environment, cognition, and service plan to ensure that violation will not happen again. 3. This will be evalauated with significant change of conditions and quarterly. 4. ED/LN are responsible to monitor and maintain compliance.

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by:

OAR411-004-0040(1) Limitations: Threats To Health And Safety (1) When conditions under OAR 411-004-0020(2)(d) to (2)(j) may not be met due to threats to the health and safety of an individual or others, provider owned, controlled, or operated residential settings must apply individually-based limitations as described in this rule. This Rule is not met as evidenced by: Based on interview and record review it was determined the facility failed to ensure Individually Based Limitations (IBLs) were completed when the need to restrict a residents’ rights arose. Findings include, but are not limited to: Refer to H1517.

1. Reviewed all other residents and determined those with violations that were able to share preferences and asked them. Preferences were documented and shared with staff through Interim service plans were put in place for staff to ask each day for resident preference if resident is able. If resident unable to answer staff to consult LN/ED for further guidance. 2. Periodic review of resident environment, cognition, and service plan to ensure that violation will not recur. 3. This will be evalauated with significant change of conditions and quarterly. 4. ED/LN are responsible to monitor and maintain compliance.

OAR411-004-0040(1) Limitations: Threats To Health And Safety (1) When conditions under OAR 411-004-0020(2)(d) to (2)(j) may not be met due to threats to the health and safety of an individual or others, provider owned, controlled, or operated residential settings must apply individually-based limitations as described in this rule. 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 ensure each resident was evaluated for activities, addressing all required elements, and failed to develop an individualized activity plan based on their activity evaluation for 2 of 2 sampled residents (#s 1 and 2) whose evaluations and services plans were reviewed. Findings include, but are not limited to: The most recent evaluations and current service plans were reviewed for Residents 1 and 2. The following was identified: a. There was no documented evidence an activity evaluation had been completed for both sampled residents that addressed the following: * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; and * Adaptations necessary for the resident to participate. b. There was no documented evidence an individualized plan was developed for both sampled residents. The need to ensure activity evaluations were completed and individualized activity plans were developed was discussed with Staff 1 (ED) and Staff 2 (MC Wellness Manager/LPN), on 08/28/25. The findings were acknowledged.

Refer to H1580.

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: