Print Inspection: CHOW009216

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed for 2 of 3 residents (#s 4 and 6) who had significant changes of condition. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 01/2025 with diagnoses including bladder cancer. The resident's clinical record from 11/10/25 through 01/30/26 was reviewed, and the following was identified: Staff documented the following weights: * 11/07/25 – 158.7 pounds; * 12/03/25 – 170.6 pounds; * 01/10/26 – 166 pounds, and * 02/04/26 – 158 pounds. From 11/07/25 to 12/03/25, the resident gained 11.9 pounds, or 7.5% of his/her bodyweight in one month, which was considered a significant weight gain and required an RN assessment that included findings, resident status, and interventions made as a result of the assessment. In an interview on 02/04/26 at 3:30 pm Staff 2 (RN) stated she reviewed all of the resident weights monthly and acknowledged she was aware of Resident 4’s weight gain but did not complete an RN assessment for this resident. The need to ensure the facility RN completed a timely assessment for the significant change of condition related to weight gain and documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 2 on 2/04/26 at 3:30 pm, and Staff 4 (Resident Care Director) and Staff 9 (Senior General Manager) on 02/05/26 at 11:22 am. They acknowledged the findings. 2. Resident 6 moved into the facility in 03/2025 with diagnoses including atrial fibrillation. The resident's clinical record from 12/04/25 through 01/31/26 was reviewed, and the following was identified: Staff documented the following weights: * 11/07/25 – 325.5 pounds; * 12/03/25 – 347.6 pounds; and * 01/10/26 – 338.4 pounds. No weight was available during the survey. From 11/07/25 to 12/03/25, the resident gained 22.1 pounds, or 6.79% of his/her bodyweight in one month, which was considered a significant weight gain and required an RN assessment that included findings, resident status, and interventions made as a result of the assessment. In an interview on 02/03/26 at 12:33 pm, Staff 2 (RN) indicated she was aware of the resident’s weight gain, spoke to the resident about the weight change but lacked documented evidence an RN assessment was completed. The need to ensure the facility RN completed a timely assessment for the significant change of condition related to weight gain and documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 2 on 2/04/26 at 3:30 pm, and Staff 4 (Resident Care Director) and Staff 9 (Senior General Manager) on 02/05/26 at 11:22 am. They acknowledged the findings.

1. RN completed late RN assessment for change of condition for Resident 4 and Resident 6. Staff will continue to monitor vitals, including weight. 2. Training will be provided to direct care staff on what qualifies as a significant weight change, including when to report to RN. RN will pull monthly weight tickler to ensure that she is capturing all significant change of conditions for weight loss/gain and then complete change of condition assessments timely. 3. This system will be evaluated during each monthly vitals check. 4. The Administrator, Resident Care Director and Community RN will oversee and monitor this to ensure compliance. The RN will be responisble to complete change of condition assessments and ensure ongoing monitoring.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by:

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 2 of 6 sampled residents (#s 1 and 5) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 12/2024 with diagnoses including spinal stenosis and Parkinson’s disease. Review of the resident’s 11/01/25 through 01/31/26 MARs and physician orders showed Resident 3 had physician orders, dated 10/15/25, to administer spironolactone 25 mg 0.5 tablet (a medication for blood pressure control) once daily. From 12/12/25 until 01/09/26, the MAR showed circled initials which indicated these medications had not been administered to the resident. Staff documented “Notified HCP [sic] need new supply.” In interview on 02/03/26 at 11:00 am, Staff 7 (Assisted Living Coordinator) confirmed the medication was not given on those days due to not arriving at the facility until 01/09/26. The need to ensure physician orders were followed as prescribed was reviewed with Staff 4 (Resident Services Director) and Staff 12 (Senior General Manager) on 02/05/26 at 11:00 am. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 01/2025 with diagnoses including Type 2 diabetes and hypertension. The resident’s clinical record from 11/03/25 to 02/02/26 was reviewed, and the following was identified: Resident 1 had physicians’ orders for losartan potassium 25 mg to be administered once daily and to hold if systolic blood pressure was less than 110, and metoprolol 50 mg to be administered twice daily and held if systolic blood pressure was less than 100. An interview with Staff 7 (Assisted Living Coordinator) on 02/03/26 at 8:36 am confirmed the facility had not been taking Resident 1’s blood pressure prior to administering either medication to determine whether the blood pressure was outside of parameters. The need to ensure physicians' orders were carried out as prescribed was discussed with Staff 3 (Regional RN), Staff 4 (Resident Services Director), and Staff 9 (Senior General Manager) on 02/04/26 at 1:20 pm. They acknowledged the findings.

1. Both Resident 5's MARS were reviewed and medication in the facility audited to ensure all medication listed on the MAR were available in-house. For Resident 1, blood pressures were added to the MAR twice daily to ensure that parameters are followed per orders. 2. Implemented new system for med techs and completed training at time of survey. New system is for med techs to run missed meds reports at the end of each shift, print out, reconcile as needed, sign/date, and then turn into the RCD. The RCD will then follow up as needed to help ensure we get medications in right away. RCD will also follow up on any missed meds and/or holes right away as well. 3. This system will be evaluated daily by the RCD. This will be evaluated weekly by the General Manager. 4. The General Manager and Resident Care Director (RCD) will be responsbile to evaluate, monitor, and ensure ongoing 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 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to conduct and record fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire drill records were reviewed on 02/03/26 at 2:10 pm. The following was identified: a. The written fire drill records did not include: * Escape route used; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; and * Evacuation time-period needed. b. There was no documented evidence alternate exit routes were used during fire drills to react to varying potential fire origin points. The need to ensure fire drills were conducted and documented as required, including comments related to residents who did not participate in the drill or evacuation, was reviewed with Staff 4 (Resident Services Director), Staff 8 (Maintenance Assistant) and Staff 12 (Senior General Manager) on 02/05/26 at 11:00 am. They acknowledged the findings.

1. The Fire Drill form for Merrill Gardens includes all required components and has been given to staff and training has been provided to the Maintenance Team and management team members. A Fire Drill was completed with this new form to include the evacuation of residents to beyond a point of fire safe doors. 2. The new form, containing all required components was given to staff and training was completed. Training included the evacuation of residents and that this needed to occur each time, every other month, at alternating times and alternating exit points. Fire Drill was then practiced as described above to ensure competency. 3. The system will be evaluated routinely (monthly) during fire drill training where fire drill documentation will be reviewed to ensure compliance. 4. The Maintenance Director, Maintenance Assistant, Administrator, and General Manager will be responsible to ensure all corrections are completed and monitored.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: