Print Inspection: CHOW012766

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?medications?orders were carried out as prescribed for?1 of?2 sampled?residents (#2) whose records were reviewed.??Findings include, but are not limited to:? Resident 2 was admitted to the facility?in 12/2021 with diagnoses?including lactose?intolerance,?hypertension?and constipation.?? The resident’s clinical record dated?04/04/2026 to 06/06/26?and?MAR dated?06/01/26?to 06/29/26?were reviewed and the following was?noted:?? From 06/01/26 to 06/29/26,?due to lack of availability,?there were 8 missed doses of medication?identified:? * Lactase?(for lactose intolerance): on 05/09/26?(two times), 05/25/26, 06/19/26 and 06/29/26;? * Mirtazapine (an?antidepressant) and?metoprolol (for blood pressure:) on?05/20/26; and? * Docusate sodium (a?stool softener): on?06/01/26.? In an interview on 06/30/26 at 9:45 am, Staff 3 (RN-Director of Health Services) stated MT staff were supposed to reorder medications when they were low (within a 10-day window). Also, the hospice nurse case manager was supposed to check with the MT at each visit to see if the resident needed?medication refills.? In an interview on 06/30/26?at 11:20 am, Staff?8?(MT)?stated?medications should have been reordered?when the resident had a five-day supply left. The?need to ensure?medications orders were carried out as prescribed?was?discussed with?Staff 1 (Memory Care Administrator), Staff 2 (Health Services Administrator), Staff?3, and Staff 5 (Assistant Administrator)?on?07/01/26?at?11:20 am. They acknowledged the findings.? ?

C0303 1.) Resident 2's med profile and MAR were reviewed. Missed medications were documented, PCP was notified and resident was assessed for adverse outcomes. 2.) MCA, DHS and Med Techs will be retrained on policy regarding ordering medications in a timely manner, this includes training Med Techs to the Med Tech checklist which includes daily auditing for medications that are running low and ordering them right then and there. 3.)MCA, DHS or designee to complete Med Cart audits weekly for 4 weeks, checking med tech's work. After consistently getting it right, move to monthly audits to confirm the med tech's work. This will be in addition to running the medications unavailable report at daily clinical Jump and following up same day on medications the Med Tech's document as unavailable. 4. Health Services Administrator is responsible for implementation and ongoing monitoring of these audits.

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

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by: Based on?observation, interview?and record review, it was determined the?facility?failed to have an?RN, PT or OT conduct a thorough assessment of the supportive device with potential restraining qualities,?documented other less restrictive alternatives evaluated prior to the use of the device?and provided?instruction to caregivers on the correct use and precautions of the device?in the resident's service plan?for 1 of 1 sampled resident (#2) who had devices with restraining qualities.??Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 12/2021 with a diagnosis of dementia.?? Throughout the survey, the resident was?observed?to?use?a geriatric?chair when s/he was out of bed.?? There was no documented evidence the device with restraining qualities had been assessed by an RN, PT or OT, the facility documented other less restrictive alternatives?and?instruction to caregivers?had been provided?on?the?correct use and precautions related to the use of the device.?? In an interview on 06/30/26?at approximately 11:30 am, Staff 3 (RN-Director of Health Services) stated she hadn’t done an assessment, documented less restrictive alternatives?evaluated prior to the use of the device?or instructed caregivers on the correct use and precautions of the?geriatric?because the resident?was?non-ambulatory and unable to get out the chair?without staff’s assistance.?? The?need to ensure?the?facility had an RN, PT or OT conduct a thorough assessment of a supportive device with potential restraining qualities,?document other less restrictive alternatives evaluated prior to the use of the device?and?provide instruction to caregivers on the correct use and precautions of the device?was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Health Services Administrator), Staff 3 and Staff 5 (Assistant Administrator)?on?07/01/26?at?11:20 am. They acknowledged the findings.?

C0340 1.) DHS immediately completed a restraint assessment, received a doctor order, provided education to staff on proper use and precautions related to the use of the device and updated service plan. 2.) MCA and DHS will be trained on policy regarding restraints and supporting devices. In addition to types of devices that have restraining qualities. 3.) DHS or designee will complete assessment and other required components at introduction of new device and at quarterly review. An environment audit will be completed by MCA or designee during quarterly review to identify potential devices with restraining qualities being used. If any are identified as being used, MCA will notify Nurse to begin assessment. 4.) Health Services Administrator is responsible for implementation and ongoing monitoring of these audits.

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 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?provide health care services?in accordance with?the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:? See C303 and?C340.? ?

Z0162 See POC for C0303 and C0340

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: