Print Inspection: CHOW010149

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 report injuries of unknown cause to the local Department office, unless an immediate facility investigation reasonably concluded and documented that the physical injury was not the result of abuse or neglect, for 1 of 1 sampled resident (# 2) who had injuries of unknown cause. Findings include but are not limited to: Resident 2 was admitted to the facility in 10/2020 with diagnoses including dementia. Review of the resident's clinical record, including progress notes from 12/07/25 through 03/09/26, identified the following: * On or about 02/24/25 the resident experienced bruising to the right lower extremity; and * On or about 03/07/26 the resident experienced a skin tear to the left shin. The bruise and skin tear represented injuries of unknown cause which were required to be reported to the local Department office, unless an immediate facility investigation reasonably concluded and documented that the physical injury was not the result of abuse. During an interview on 03/19/26 at 10:55 am, Staff 3 (LPN) reported there were no documented investigations completed for the above incidents. There was no documented evidence the facility immediately investigated the resident’s skin injuries to rule out suspected abuse or neglect, and there was no documented evidence the facility reported the incidents to the to the local Department office. The need to ensure all incidents and injuries of unknown cause were immediately investigated to rule out suspected abuse, or reported to the Department office if abuse could not be ruled out, was discussed with Staff 1 (Memory Care Administrator) and Staff 4 (ED) on 03/19/26 at 11:10 am. They acknowledged the findings. Survey requested the facility report the above incidents to the local Department office. Confirmation that the incidents were reported was received on 03/19/26 at 12:37 pm.

1.The identified incidents involving resident #2 were immediately reviewed. An investigation was completed to assess the injuries of unknown origin. The incidents were reported to the local Department office as required. 2. The Med Tech documented skin issues in the progress notes but did not fill out an incident report. That is where the process broke down. The incident report triggers the investigation to either rule out abuse or report to APS, as well as, putting out a TSP and the Skin Log. Training provided to Med Techs on when to fill out incident reports. Moreover, with the transition to Point Click Care progress notes flow to the 24 hour report for the management team to review daily. 3. Daily review of the 24 hour report, to identify progress notes that do not have a needed corresponding incident report. 4. ED, MC, and Nurse will be responsible for ensuring compliance with reporting and investigation requirements.

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 411-057-0140(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 and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C231.

Refer to C231.

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: