Print Inspection: FEOS010147

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by: Based on interview and record review, it was?determined?the facility?failed to?notify the physician or other practitioner when a resident refused to consent to orders for 1 of 1?sampled?resident (5) who?had repeated medication?refusals. Findings include, but are not limited to:? Resident 5 moved into the Memory Care Community in 02/2026 with diagnoses?including Parkinson’s disease and dementia. The resident's 02/04/26 through 03/16/26 MARs and physician orders were reviewed.? Staff documented the resident refused carbidopa/levodopa on nine occasions and entacapone on eight occasions,?both?medications?prescribed to manage symptoms of?Parkinson’s disease. There was no documented evidence that the facility notified the resident’s physician of?the repeated medication?refusals as?required.?? During an interview on 03/18/26 at 10:45 am, Staff 2 (RN) confirmed she was unable?to?locate?documentation showing the physician?had been notified.? The need to notify the?physician/practitioner when a resident refused to consent to orders was discussed with Staff 1 (ED),?Staff 2, and Staff?15?(RN/MSW) at 3:30?pm on 03/19/26. They acknowledged the findings.? ??

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure they accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan and failed to ensure established care time was resident specific rather than a predetermined average for 5 of 5 sampled residents (#s 1,2, 3, 4, and 5) whose ABST evaluations were reviewed. Findings include, but are not limited to:? Record?reviews?of Resident 1, 2, 3, 4, and 5’s ABST evaluations identified the facility used predetermined average times for care elements rather than resident-specific care times as outlined in each resident’s individual service plan. The ABST evaluations did not accurately capture the care time and care elements staff provided to each resident.? Staff 1 (ED) confirmed, during an interview on 03/19/26 at 11:40 am, the facility’s proprietary ABST generated predetermined times for care elements.? The need to ensure established care time was resident-specific rather than a predetermined average was reviewed with Staff 1, Staff 2 (RN), and Staff?15?(RN/MSW) at 3:30 pm on 03/19/26. They acknowledged the findings.??

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 not limited to:? Refer to?C362.

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 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:? Refer to?C305.?