Print Inspection: RL001136

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the residents were treated with dignity and respect in a homelike environment related to medical treatments provided for a sampled resident (#2) and an unsampled resident in the dining room and meal delivery service for multiple unsampled residents who ate in their apartments. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 06/2019 with diagnoses including Hepatitis B, Chronic Hepatitis C, and dementia. On 11/08/24 at 9:23 am, Staff 10 (MT/Treatment Aid) was observed providing wound care to Resident 2’s right ankle in the dining room. Two other residents were seated at the table while the treatment was provided and multiple unsampled residents were in the dining room seated at other tables. 2. On 11/06/24 at 1:22 pm, Staff 10 was observed providing treatment to an unsampled resident’s hand in the dining room. The resident was seated at a table playing a game with several other residents, and there were residents seated at other tables nearby. 3. During lunch meal delivery on 11/06/24 through 11/08/24, staff were observed to deliver meals to residents who ate in their apartments in Styrofoam clamshell containers, with paper cups and plastic cutlery. The need to ensure residents' right to be treated with dignity and respect and to receive services in a manner that promoted privacy and dignity was discussed with Staff 1 (Administrator), Staff 2 (Owner), Staff 4 (RN), and Staff 6 (RCC) on 11/12/24 at 2:25 pm. They acknowledged the findings.

1. In regard to resident 2, staff will be retrained to infection control policies regarding body fluids hygiene-proper glove use, and to use a private area.- TA and MT's have all been notified of not doing treatments in the dining room and must be in private rooms or med room. Remove all styrofoam/plastic utensils only during pandemic situation 2. Weekly auditing of all dressing changes and meal serving 3. 1st month audit weekly 2nd month audit every 2 weeks x 4. Admin/LN/RCC

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 promptly investigate reports of abuse and suspected abuse related to resident-to-resident altercations for 1 of 1 sampled resident (# 2) whose incidents were reviewed. Findings include, but are not limited to: Resident 2 was admitted to the facility in 06/2019 with diagnoses including Hepatitis B, Chronic Hepatitis C, and dementia. Review of the 08/08/24 through 11/06/24 progress notes, 10/09/24 service plan, and incident reports indicated the following: * On 08/31/24 progress notes indicated “Resident had a [sic] argument with 116 at the table during dinner time. Words were exchanged. CG nor med tech heard the words.” Resident 2 “got up in [his/her] chair and started going for 116. Med tech had to intervene…”; and * On 09/30/24 progress notes indicated kitchen staff reported to Staff 1 (Administrator) “they heard yelling in the kitchen last night for dinner.” The camera footage was reviewed, and she observed another resident sitting in Resident 2’s seat “while [Resident 2] was getting ice.” Resident 2 “nudged” the other resident when “[s/he] got up and moved to the other side.” On 11/08/24, Staff 1 (Administrator) acknowledged there was no documented evidence the resident-to-resident incidents were investigated to rule out abuse or suspected abuse. The need to investigate resident incidents to rule out abuse or suspected abuse was discussed with Staff 1, Staff 2 (Owner), Staff 4 (RN), and Staff 6 (RCC) on 11/12/24 at 2:25 pm. They acknowledged the findings.

1. Review APS reporting guidelines. Retrain staff to abuse reporting policy Resident 2 chart was corrected to be in compliance for IR that needed to rule out abuse and neglect due to yelling at the day of survey. 2. Incident reports will be used to include verbal disagreements to alert admin to investigate for potential abuse. Staff retrained on use of IR vs normal charting for incidents. 3. Daily audit of IR for incidents and timely reporting 4. Admin/RCC

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents’ current status and care needs and provided clear direction regarding the delivery of services for 3 of 4 sampled residents (#s 1, 4, and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 11/2021 with diagnoses including Alzheimer’s disease. The resident’s 09/16/24 service plan was reviewed, observations of the resident were made, and interviews with staff were completed. The service plan was not reflective of the resident’s current care needs related to requiring two staff for ADL care and transfers. The need to ensure service plans were reflective of residents’ current status and care needs and provided clear direction to staff regarding the delivery of services was discussed with Staff 1 (Administrator), Staff 2 (Owner), Staff 4 (RN), and Staff 6 (RCC) on 11/12/24. They acknowledged the findings. 2. During the acuity interview on 11/06/24, Staff 6 (RCC) and Staff 10 (MT/Treatment Aid) indicated Residents 4 and 5 had an intimate relationship. They reported the residents had been evaluated for their ability to consent to the relationship, the residents’ families were aware of the relationship and were “OK” with it, and that Resident 4 sought out Resident 5. Interviews with staff and review of service plans, temporary service plans, and progress notes dated 08/09/24 through 11/07/24 showed the service plans were not reflective of current behaviors and did not provide clear direction to staff in the following area: * A sexual relationship between Residents 4 and 5. Interviews with staff revealed they were aware of the relationship between the residents and had witnessed the couple together within the last month. Staff reported they usually attempted to re-direct Resident 4 when they found him/her pursuing Resident 5 or found them alone in Resident 5’s apartment. The need for service plans to be reflective of residents’ current status and care needs, including behaviors with other residents, and to provide clear direction to staff regarding the provision of care was discussed with Staff 1, Staff 2 (Owner), Staff 4 (RN), and Staff 6 (RCC) on 11/12/24. They acknowledged the findings.

1. Resident 1 has been re evaluated by nursing and is a 1 person assist. SP has been updated and staff have been notified and has signed updated SP. -Resident 4 and resident 5 SPs were updated to reflect consenting and non concenting of their sexual behaviors. SP's were updated to reflect this information. TSP for resident 4 and 5 state the following: IF NONCONSENSUAL IMMEDIATELY INTERVENE BY REDIRECTING RIGHT AWAY AND KEEPING BOTH PARTIES SEPERATED, ALSO NOTIFY ADMIN/LN/MT/RCC WHAT TO WATCH FOR ON THE FOLLOWING: • What is the potential sexual relation occurring (kissing, cuddling, holding hands, feeling each other) • S/sx of mutual consent aeb: touching/feeling reciprocation nodding head “yes”, open body language (relaxed, loose, turning towards), sounds of enjoyment • S/sx of nonconsensual relations aeb: avoiding eye contact/touch, moving away, shaking head “no”, closed body language (tense, stiff, turning away), crying and/or looking fearful. - Should they be involved with intimacy, afterwards staff will ensure they are not showing signs of distress or outside of baseline confusion (anger, crying, isolation, vocalizing suicidal thoughts, etc…) and the LN will evaluate both afterwards each time. -Nursing will take a class on "sexual expression and intimacy" per Corrective Action Coordinator recommendation 2. Service plan review and clarification with staff regarding monitoring sexual/relationship safety. See updated Sexual/relationship policy. 3. Monitor daily for relationships when discovered at all times every encounter. 4. Staff, RCC, Admin, Team

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 interview and record review, it was determined the facility failed to ensure actions or interventions were determined, documented, and communicated with staff on all shifts for changes of condition and failed to ensure changes were monitored, with progress noted at least weekly until resolution, for 3 of 4 sampled residents (#s 2, 4 and 5) who experienced changes in the areas of skin, medication changes, resident-to-resident altercations, and sexual relationships. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 06/2019 with diagnoses including Hepatitis B, Chronic Hepatitis C, and dementia. a. The resident's 08/08/24 through 11/06/24 progress notes, 10/09/24 service plan, and temporary service plans (TSPs) were reviewed. The following was revealed: * 08/30/24 - scrapes to both knees after a fall; * 08/31/24 – resident-to-resident altercation; * 09/30/24 – resident-to-resident altercation; and * 10/23/24 - “discoloration/bruising” on left arm. There was no documented evidence the facility determined what resident-specific actions or interventions were needed for the resident, communicated the determined actions or interventions to staff, and/or monitored the resident with progress documented at least weekly until resolved. b. Resident’s August and September 2024 MARs were reviewed and indicated Resident 2 was out of the following medications on the following dates: * 08/29/24 through 09/09/24: acyclovir (for a viral illness), citalopram (for depression), and folic acid (a supplement); * 08/28 (pm dose) through 09/03/24: buspirone (for anxiety); * 08/30/24 through 09/09/24: mirtazapine (an appetite enhancer); * 09/02/24 through 09/09/24: ferrous sulfate (a supplement); * 09/24/26 through 09/26/24: acyclovir; and * 09/13/24 through 09/26/24: melatonin (a sleep aid). There was no documented evidence the facility determined what resident-specific actions or interventions were needed for the resident, communicated the determined actions or interventions to staff, and/or monitored the resident for adverse reactions resulting from not taking these medications, with progress documented at least weekly until resolved. The need to ensure actions or interventions for short-term changes of condition were determined, documented, and communicated to staff on each shift and changes of condition were monitored, with weekly progress noted through resolution, was discussed with Staff 1 (Administrator), Staff 2 (Owner), Staff 4 (RN) and Staff 6 (RCC) on 11/12/24 at 2:25 pm. They acknowledged the findings. 2. During the acuity interview on 11/06/24, Staff 6 (RCC) and Staff 10 (MT/Treatment Aid) indicated Residents 4 and 5 had an intimate relationship. They reported the residents had been evaluated for their ability to consent to the relationship, the residents’ families were aware of the relationship and were “OK” with it, and that Resident 4 sought out Resident 5. Interviews with staff and review of Resident 4 and 5’s service plans, temporary service plans, progress notes dated 08/09/24 through 11/07/24, and evaluations were completed. A Brief Interview for Mental Status (BIMS) for Resident 5, dated 09/16/24, was provided on 11/07/24. The evaluation noted staff were unable to complete the interview. In the areas which were addressed, Resident 5 scored seven, indicating “severe cognitive impact.” There were no other documented evaluations in the resident’s record related to his/her ability to consent to a sexual relationship. In an interview with Staff 1 (Administrator) and Staff 3 (Regional RN Support) on 11/08/24 at 1:05 pm, Staff 1 reported she had determined Resident 4’s ability to consent to a sexual relationship by speaking with him/her to determine if s/he understood the difference between “yes” and “no.” She stated she had a Spanish-speaking staff member speak with the resident also, since Spanish was the resident’s first language. There was no documented evidence of Staff 1’s verbal evaluation of Resident 4. There were no other documented evaluations in the resident’s record related to his/her ability to consent to a sexual relationship. Staff 1 provided a BIMS for Resident 4 which was completed on 11/08/24. The documentation on the BIMS noted staff were unable to complete the interview. In the areas which were completed, the resident scored two, indicating “severe cognitive impact.” There was nothing documented in the residents’ charting notes related to the relationship between Residents 4 and 5. In staff interviews on 11/08/24, they reported they had found both residents in Resident 5’s apartment, unclothed from the waist down. Staff indicated they had not documented any of their observations of the couple being intimate, although they had observed the behavior in the last month. Staff stated they usually attempted to re-direct Resident 4 when they found him/her pursuing Resident 5 or found them alone in Resident 5’s apartment. In the 11/08/24 interview with Staff 1, she acknowledged there were no documented instructions to staff regarding: * How to respond to Resident 4 and 5’s sexual behavior; * How to keep both residents safe; * How to maintain and protect their privacy and dignity; * What assistance the residents may require following intimacy; * How they may exhibit signs of distress; * What to do if either resident were unable to speak or consent; and * How and what to document regarding the residents’ behavior. She also acknowledged staff were not monitoring the residents for: * Emotional and physical signs and symptoms of distress; * Changes in behaviors; and * Ongoing cognitive status and ability to consent. There was no documented evidence Resident 4 and 5’s behaviors had been evaluated or that staff had monitored the behaviors. During the survey, from 11/06/24 through 11/12/24, Residents 4 and 5 were not observed alone together or in each other’s apartment. The need for resident behaviors to be evaluated and monitored was discussed with Staff 1 (Administrator), Staff 2 (Owner), Staff 4 (RN), and Staff 6 (RCC) on 11/12/24. They acknowledged the findings.

Resident 2: 1A. Note was entered by nurse to close out tsp for scrapes as they were fully healed. Review COC guidelines with nursing to follow until resolved. Resident 2: 1B. COC will be implemented for all missing or skipped prescribed meds-non OTC meds. This is a new protocol. The nurse reviewed resident vitals and behaviors for the dates meds were missed. Wounds will not be combined. Each one will have their own COC. Resident 4 and 5 BIMS was completed, nurse evaluated both residents and both were added for monitoring for sexual activity/intimacy. This continues even though no recent contact. They will continue being monitored until next survey review. Staff will ensure privacy if they become sexually intimate. LN will evaluate quarterly and every time sexual intimacy occurs. If resident 4 and 5 should become intimate, Staff will ensure they are not showing signs of distress or confusion outside of baseline. Any assistance needed with hygiene will be offered afterward. LN will evaluate afterwards again. Review sexuality and dementia training. Implement recommended practice to confirm safe sexual relationships. See sexual relationship policy. -Nursing held meeting with med techs and treatment aid instructing them to initiate a charting and tsp for missing meds. 2. Weekly meeting RN/LPN to review COC's via: med/admin dashboard Staff to do a training on sexuality and persons with dementia on OCP.com 3. Weekly x 4 Monthly x 2 Resident 4 and 5 will be monitor daily when discovered 4. RCC/Admin/LN

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 maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment for 2 of 2 sampled residents (#s 1 and 2) and multiple unsampled residents dependent on staff for care needs and meal service. Findings include, but are not limited to: 1. The following observations were made in the dining room: a. Observations on 11/06/24 and 11/08/24 were made of Staff 10 (MT/Treatment Aid) providing treatments to one sampled resident (#2) and an unsampled resident while seated in the dining room. No observations were made of staff sanitizing the area following the treatments. Refer to C 200. b. Observations of meal service were conducted on 11/06/24 and 11/07/24. Caregiving staff were observed providing one-to-one feeding assist to Resident 1 and another unsampled resident without wearing a protective covering over potentially contaminated clothing. Maintaining effective infection prevention and control while providing medication treatments and meal service was reviewed with Staff 1 (Administrator), Staff 2 (Owner), Staff 4 (RN), and Staff 6 (RCC) on 11/12/24 at 2:25 pm. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 11/2021 with diagnoses including Alzheimer’s disease. On 11/08/24 Staff 20 (CG/MT) and Staff 15 (CG) were observed providing incontinence care for Resident 1. Staff 20 did not change gloves or perform hand hygiene after removing a used brief and before touching a clean brief and the resident’s clothes. The need for staff to follow hand hygiene protocol was discussed with Staff 1 (Administrator), Staff 2 (Owner), Staff 4 (RN), and Staff 6 (RCC) on 11/12/24. They acknowledged the findings.

See POC-C 200

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept for all medications ordered by a physician or other legally recognized prescriber for 2 of 2 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 11/2021 with diagnoses including Alzheimer’s disease. The resident’s 09/01/24 through 11/06/24 MARs were reviewed. The following was identified: * Multiple PRN topical skin treatments included instructions to apply “to affected area,” rather than to a specific location; and * Monthly vitals listed on the MAR included language for parameters for blood pressure and pulse, but they were blank. The need to ensure residents’ MARs were accurate and included resident-specific parameters was discussed with Staff 1 (Administrator), Staff 2 (Owner), Staff 4 (RN), and Staff 6 (RCC) on 11/12/24. They acknowledged the findings. 2. Resident 2 was admitted to the facility on 06/2019 with diagnoses including Hepatitis B, Chronic Hepatitis C, and dementia. The resident’s 08/01/24 through 11/06/24 MARs were reviewed. The following was identified: a. The MAR lacked clear parameters and instructions to unlicensed staff for when the following PRN medication should be administered: * Multiple PRN topical skin treatments including cream, ointment, and powder for skin integrity with no clear instructions for unlicensed staff on which to use first. * Two PRN eye drops were prescribed. One medication, Azelastine 0.5% eye drops, indicated “eye drops” as reason for use and both eye drops lacked instructions on which to administer first. b. There were blanks on the MAR for the following: * 08/28/24: acyclovir (for a viral illness), buspirone (for anxiety) am dose, citalopram (for depression), folic acid (a supplement), mirtazapine (an appetite enhancer), tenofovir (for hepatitis), Vitamin B-12 (a supplement), and ferrous sulfate (a supplement); * 09/09/24: ferrous sulfate, mirtazapine, buspirone pm dose; * 10/19/24: mupirocin (a skin issue); and * 11/01/24: mupirocin (a skin issue). On 11/12/24 at 10:00 am, Staff 1 (Administrator) was not able to confirm if the medications and/or treatments were administered or not. The need to ensure the residents’ MARs were accurate and included resident-specific parameters was discussed with Staff 1, Staff 2 (Owner), Staff 4 (RN), and Staff 6 (RCC) on 11/12/24. They acknowledged the findings.

1. Resident 2, All topical treatments will have specific treatment orders. All blood pressures will have parameters. 2. All PCP's will be notified via: fax when a new medication will be needed with request for parameters. 3. Weekly audit x 4 Monthly x 2 4. LPN/RN

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’s proprietary Acuity-Based Staffing Tool (ABST) did not accurately capture care time for care that staff were providing to each resident using resident-specific care time for 3 of 4 sampled residents (#s 1, 4, and 5), and the facility did not develop a staffing plan for each shift which addressed the unscheduled needs of all residents. Findings include, but are not limited to: Current service plans for Residents 1, 4, and 5 were reviewed during survey and were found to not be reflective of the residents’ current status and care needs. During interviews on 11/08/24 and 11/12/24, Staff 1 (Administrator) and Staff 2 (Owner) reported the resident service plans provided the data for their proprietary ABST. For each required ADL, care needs were determined to require minimal, medium, or maximum time, which were rated as 1, 2, or 3 points, respectively. Staff 1 reported each point equaled five minutes. The maximum time for any ADL care was 15 minutes, which did not account for the extra time needed for residents requiring two-person care and/or transfers. Because the service plans for Residents 1, 4, and 5 did not accurately reflect the residents’ current status and care needs, the ABST did not accurately reflect the time needed for staff to provide care. This caused the ABST-generated staffing plan to be incorrect. The need for the ABST to accurately capture care time and care elements that staff were providing to each resident and for the staffing plan to meet the scheduled and unscheduled needs of all residents was discussed with Staff 1, Staff 2, Staff 4 (RN), and Staff 6 (RCC) on 11/12/24. They acknowledged the findings.

1Acuity tool will be updated to reflect Pt care time needs and unscheduled needs based on staff/nursing input. 2. Daily reviews to ensure accuity is accurate 3. Weekly x 2 months -Every 2 weeks for 1 month 4.Admin

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to routinely update the posted staffing plan and failed to ensure the staffing plan accounted for the unscheduled needs of all residents in the facility for each shift. Findings include, but are not limited to: Review of the facility’s posted staffing plan indicated the following: * One MT and three CGs were scheduled for day shift (6:00 am to 6:30 pm); and * One MT and two CGs were scheduled for the overnight (NOC) shift (6:00 pm to 6:30 am). In an interview with Staff 1 (Administrator) on 11/08/24, she reported she routinely scheduled three CGs and one MT for NOC shift. Review of the facility’s staffing schedule for 10/2024 and 11/2024 revealed the following: * In 10/2024, three CGs were scheduled for NOC shift on 18 of 31 days; and * From 11/01/24 through 11/12/24, three CGs were scheduled for NOC shift on nine of 12 days. The facility provided a plan to ensure there were at least four staff (one MT and three CGs) on NOC shift every night until they updated the ABST data to account for the unscheduled needs of all residents. The need to ensure the posted staffing plan was routinely updated and that the staffing plan accounted for the scheduled and unscheduled needs of all residents was discussed with Staff 1, Staff 2 (Owner), Staff 4 (RN), and Staff 6 (RCC) on 11/12/24. They acknowledged the findings.

See C-362 POC 1.Staffing plan will accurately reflect acuity needs to ensure adequate staffing to meet resident needs. 2. Additional FTE added to night coverage. 3,4 see C362 POC

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to routinely update the posted staffing plan and failed to ensure the staffing plan accounted for the unscheduled needs of all residents in the facility for each shift. Findings include, but are not limited to: Review of the facility’s posted staffing plan indicated the following: * One MT and three CGs were scheduled for day shift (6:00 am to 6:30 pm); and * One MT and two CGs were scheduled for the overnight (NOC) shift (6:00 pm to 6:30 am). In an interview with Staff 1 (Administrator) on 11/08/24, she reported she routinely scheduled three CGs and one MT for NOC shift. Review of the facility’s staffing schedule for 10/2024 and 11/2024 revealed the following: * In 10/2024, three CGs were scheduled for NOC shift on 18 of 31 days; and * From 11/01/24 through 11/12/24, three CGs were scheduled for NOC shift on nine of 12 days. The facility provided a plan to ensure there were at least four staff (one MT and three CGs) on NOC shift every night until they updated the ABST data to account for the unscheduled needs of all residents. The need to ensure the posted staffing plan was routinely updated and that the staffing plan accounted for the scheduled and unscheduled needs of all residents was discussed with Staff 1, Staff 2 (Owner), Staff 4 (RN), and Staff 6 (RCC) on 11/12/24. They acknowledged the findings.

OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff (6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF. (a) Annual infectious disease training requires the following: (A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training. (B) Annual in-service training must be documented in the employee record. (b) Biennial LGBTQIA2S+ training requires the following: (A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff. (i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite. (ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. (vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state. (D) The proposal for training submitted by a facility, entity, or individual shall include: (i) The regulatory criteria described in paragraph (C) of this section as part of the proposal. (ii) The following elements must be included in the proposal: (I) A statement of the qualifications and training experience of the facility, individual or entity providing the training; (II) The proposed methodology for providing the training either online or in person. (III) An outline of the training. (IV) Copies of the materials to be used in the training. (iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision. (c) Annual Home and Community-Based Services (HCBS) training requires the following: (A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations. (B) Annual in-service training must be documented in the employee record. (C) These annual trainings will be required as of April 1, 2025. (7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF. (a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire. (b) Requirements for annual in-service dementia training: (A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care. (B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter. (C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above. (D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia. (E) The facility shall determine the competency of direct care staff in dementia care in the following ways: (i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19). (ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff. (iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency. (8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to designate one management staff and one direct care staff to serve as points of contact for the facility regarding compliance with the LGBTQIA2S+ protections pre-service and biennial training requirements. Findings include, but are not limited to: In an interview on 11/08/24, Staff 1 (Administrator) reported that two employees had not been designated to serve as points of contact for the facility related to compliance with the LGBTQIA2S+ protections training requirements. She stated she was unsure what those employees were supposed to do, so she had not designated anyone. The need to comply with the LGBTQIA2S+ protections rule related to designating two employees, one to represent management and one to represent care staff, to serve as points of contact regarding compliance was discussed with Staff 1, Staff 2 (Owner), Staff 4 (RN), and Staff 5 (RCC) on 11/12/24. They acknowledged the findings and designated staff prior to survey exit.

1. Residents responses were documented. LGBTQ Resource identified for community Admin and DNS was decided at the time of survey date. 2. OCP training was done by all staff before survey date. 3. Monthly x 3 months 4. Admin

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 provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to: Fire and life safety records, dated between 04/2024 and 10/2024, were reviewed and identified the following: There was no documented evidence the facility consistently provided fire and life safety training to staff on alternate months of fire drills. The need to ensure the facility provided fire and life safety instruction to staff on alternate months was discussed with Staff 1 (Administrator) at 2:40 pm on 11/07/24. She acknowledged the findings. No further information was provided.

1. The staff meeting schedue has been changed and the protocol going forward will be to include disaster plan review on alternating months from fire drills. December has been completed with these changes and another meeting will be scheduled on January 8th to stay in compliance and will be ongoing every other month thereafter. 2. Monthly auditing of life and safety binder 3. Monthly x 6 4 Admin, Activities, RCC

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all chemicals and other toxic materials were in a locked storage unit and exterior pathways were maintained in good repair. Findings include, but are not limited to: During a tour of the MCC on 11/06/24 at 9:26 am, the following was identified: a. Observations revealed paint and other toxic materials were in unlocked storage, accessible to residents, in the following areas: * In the dining room area, also used for activities, were unlocked cabinets and drawers, including a rolling cart, that contained disinfectant wipes, acrylic paints and markers, hairspray, mani-pedi scrub, fingernail polish, and fingernail polisher remover; and * A can of house paint was on the ground in the courtyard. b. Potential fall hazard areas were identified for residents who use the courtyard and included: * Multiple drop-offs measuring up to two inches were noted along sidewalk edges in the courtyard; and * One section of the sidewalk by the storage shed was cracked, uneven, and in need of repair. The need to ensure all chemicals and other toxic materials were in a locked storage unit and exterior pathways were maintained in good repair was discussed with Staff 1 (Administrator) and Staff 7 (Maintenance Lead) on 11/06/24 and 11/08/24. They acknowledged the findings.

1. Concrete repair was completed on survey day by maintenance for the outside. A lock was placed on the dining room cabinet on survey day by maintenance and removal of all chemicals. -Exterier will be audited by maintanence 2. Weekly audit to ensure chemicals are to remain under locked designated area. 3. Weekly x 4 then monthly thereafter via maintenance safety log. This will be returned to admin monthly. 4. Maintenance, Admin, RCC

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the building was clean and in good repair. Findings include, but are not limited to: Observations of the MCC on 11/06/24 showed the following areas in need of cleaning and/or repair: * In the dining room, cabinets and drawers were chipped, scratched, and had gouges, there was blue material was on the ceiling near the fire sprinkler, the flooring had multiple gaps, and two lightbulbs were burned out on the ceiling near the entrance; * A handrail by the laundry room had a gouge that created a splinter and the baseboards across from the laundry room had multiple gouges and chipped paint; and *There was a sticky substance on the cabinet doors in the laundry room, as well as multiple holes in the wall behind the washers and dryers. The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Administrator) and Staff 7 (Maintenance Lead) on 11/07/24. They acknowledged the findings.

1. Ceiling was on survey day by maintenance. Flooring will be repaired by a flooring company to meet compliance Cabinets will be refurnished and painted to eliminate scratches/cracks 2. Maintenance will be notified immediatley when environment needs to be updated via maintenance log. 3. Monthly until repaired is completed. Estimated repair for flooring will be done by 3/31/25 Dry wall repairs completed by maintenance by 1/11/2025. - monthly 4. Maintenance

OAR 411-054-0200 (7)(b-d) Housekeeping and Laundry (b) HOUSEKEEPING AND SANITATION.(A) A RCF must have a secured janitor closet for storing supplies and equipment, with a floor or service sink.(B) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.(c) LAUNDRY FACILITIES. Laundry facilities may be located to allow for both resident and staff use, when a time schedule for resident-use is provided and equipment is of residential type. When the primary laundry is not in the building or suitable for resident-use, a RCF must provide separate resident-use laundry facilities. A CF is not required to provide resident-use laundry services.(A) Laundry facilities must be operable and at no additional cost to the resident.(B) Laundry facilities must have space and equipment to handle laundry-processing needs. Laundry facilities must be separate from food preparation and other resident-use areas.(C) On-site laundry facilities, used by staff for facility and resident laundry, must have capacity for locked storage of chemicals and equipment.(D) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.(d) SOILED LINEN PROCESSING. For the purpose of this rule, "soiled linens and soiled clothing," means linens or clothing contaminated by an individual's bodily fluids (for example, urine, feces, or blood).(A) There must be a separate area with closed containers that ensure the separate storage and handling of soiled linens and soiled clothing. There must be space and equipment to handle soiled linen and soiled clothing processing needs that is separate from regular linens and clothing.(B) Arrangement must provide a one-way flow of soiled linens and soiled clothing from the soiled area to the clean area and preclude potential for contamination of clean linens and clothing.(C) The soiled linen room or area, must include a flushing rim clinical sink with a handheld rinsing device and a hand wash sink or lavatory.(D) When washing soiled linens and soiled clothing, washers must have a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant is used.(E) Personnel handling soiled laundry must be provided with waterproof gloves.(F) Covered or enclosed clean linen storage must be provided and may be on shelves or carts. Clean linens may be stored in closets outside the laundry area.(G) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure soiled linens and soiled clothing were kept in closed containers to ensure the separate storage and handling of the soiled items, staff were following the facility's procedures relating to a one-way flow of soiled items from the soiled area to the clean area in order to preclude the potential for contamination of clean linens and clothing, and washers for soiled laundry had a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant was used. Findings include, but are not limited to: The facility laundry room was toured on 11/06/24 at 1:30 pm, and revealed the following: * Two doors allowed access into the laundry room, one located near the hopper and the second located by the dryers. The second door was blocked by a laundry cart full of clothes; and * A full trash bag was on the floor next to one of the washing machines. Multiple care staff were interviewed on 11/06/24 and 11/07/24 regarding the laundry process for soiled items and revealed the following: * Staff 16 (CG) confirmed if a washer or hopper was not available, the bag of soiled linen and/or clothing would be placed on the floor. * Staff 16 and Staff 22 (CG) confirmed they only use the door near the hopper to enter and exit. Staff 22 indicated the second door was “used for emergencies only.” * Staff 22 indicated that the chemical disinfectant product provided to staff was new, and she was not sure how much to use. She stated she added the chemical disinfectant directly into the washing machine and started the load. On 11/07/24 at 12:50 pm, Staff 1 (Administrator) described the process for handling soiled linen and soiled clothing. She acknowledged closed containers were not used and staff enter and exit through the same door, near the hopper. She confirmed the facility had a new sanitizer being used as a chemical disinfectant but was not able to verbalize the amount and process to ensure the new product was used as a disinfectant. The instructions for using the sanitizer as a disinfectant indicated two capfuls were added into one gallon of cold water and soiled items needed to soak for 15 minutes. This information was reviewed with Staff 1 on 11/07/24 at 1:23 pm. She acknowledged the findings and stated she would provide these instructions to staff. The need to ensure soiled items were stored in a closed container, staff followed a one-way flow of traffic for soiled laundry and washers for soiled laundry had a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant was used was discussed with Staff 1 and Staff 7 (Maintenance Lead) on 11/07/24. They acknowledged the findings.

1. Retraining staff to proper Infection Control Practices with handling soiled/clean linen was completed on all staff meeting of 11/09/24. -Laundry-Management Soiled Laundry How to use sanitizer: MSDS data sheet and instruction date-Reviewed-All staff instruction posted in Laundry room. -Staff will be watched weekly and periodically reviewing "handling soiled items and disinfectants" at all staff meetings. 2. Designate proper flow of linens and signs posted 3. Management team will monitor and correct performance weekly for 4 weeks, then monthly x 2 and quarterly thereafter. 4. Admin/LN/RC

OAR 411-054-0200 (9) Plumbing Systems (9) PLUMBING SYSTEMS. Plumbing systems must conform to the building codes in effect at the time of facility construction.(a) Hot water temperature in residents' units must be maintained within a range of 110 - 120 degrees Fahrenheit.(b) Hot water temperatures serving dietary areas must meet OAR 333-150-0000 (Food Sanitation Rules).(c) An outside area drain and hot and cold water hose bibs must be provided for sanitizing laundry carts, food carts, and garbage cans. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure hot water temperatures in residents' units and common areas were maintained within a range of 110 to 120 degrees Fahrenheit. Findings include, but are not limited to: A tour of the facility, on 11/07/24 at 10:10 am, revealed the following: * The hot water in three of three sampled residents' bathroom sinks was between 125.9 and 132.4 degrees Fahrenheit (F). At approximately 10:23 am on 11/07/24, Staff 7 (Maintenance Lead) was notified of the water temperature findings and stated he would adjust the temperatures. At 10:40 am, findings were reviewed with Staff 1 (Administrator) and the surveyor requested staff assist residents when they used the bathroom sinks, when possible, until the water temperature had been adjusted. At approximately 12:40 pm on 11/07/24, Staff 7 indicated he had adjusted the water temperatures, and the adjustments would be monitored for effectiveness. On 11/07/24 at approximately 12:45 pm, with Staff 7 present, water temperatures between 115.9 and 119.8 degrees F were confirmed in three of three resident bathroom sinks. The need to ensure hot water temperatures in resident units and common areas were maintained between 110 and 120 degrees F was discussed with Staff 1 on 11/07/24. She acknowledged the findings. Based on observation and interview, it was determined the facility failed to ensure hot water temperatures in residents' units and common areas were maintained within a range of 110 to 120 degrees Fahrenheit. Findings include, but are not limited to: A tour of the facility, on 11/07/24 at 10:10 am, revealed the following: * The hot water in three of three sampled residents' bathroom sinks was between 125.9 and 132.4 degrees Fahrenheit (F). At approximately 10:23 am on 11/07/24, Staff 7 (Maintenance Lead) was notified of the water temperature findings and stated he would adjust the temperatures. At 10:40 am, findings were reviewed with Staff 1 (Administrator) and the surveyor requested staff assist residents when they used the bathroom sinks, when possible, until the water temperature had been adjusted. At approximately 12:40 pm on 11/07/24, Staff 7 indicated he had adjusted the water temperatures, and the adjustments would be monitored for effectiveness. On 11/07/24 at approximately 12:45 pm, with Staff 7 present, water temperatures between 115.9 and 119.8 degrees F were confirmed in three of three resident bathroom sinks. The need to ensure hot water temperatures in resident units and common areas were maintained between 110 and 120 degrees F was discussed with Staff 1 on 11/07/24. She acknowledged the findings.

1. Maintenance adjusted the water heater temp to bring the water temperatures to bring all rooms within 110 F to 120 F. 2. Safety check list will be created to monitor temps monthly. C 510- Maintenance log 3 Weekly x 3 Monthly x 3 4. Maintenance

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to: Observations of the MCC environment on 11/06/24 revealed there were no functioning exit door alarms that alerted staff when residents exited into the secured courtyard. On 11/07/24, between 10:50 am and 10:55 am, multiple doors that exited to the courtyard did not have functioning exit door alarms. During a walk-through of the environment on 11/07/24 at 12:50 pm, Staff 1 verified that the alarms had been “off” yesterday and earlier this morning but were all turned on at time of walkthrough. On 11/07/24 at 12:50 pm, the need to ensure exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the building was discussed Staff 1 and Staff 7. They acknowledged the findings.

1. Door alarms were placed and used same day of survey. Batteries were changed and working properly. Alarms will be on at all times. 2. Door alarms reprogrammed to alarms with all openings and tested. Off switches removed RCC and Admin will walk through working hours to ensure alarms are working properly. 3. Weekly x4 Monthly x 2 4. Admin, RCC, Team

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure individual rights of privacy and dignity in regard to medical treatments provided for a sampled resident (#2) and an unsampled resident, and meal service for multiple unsampled residents who ate in their apartments. Refer to C 200.

Refer to POC C 200

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their unit. Findings include, but are not limited to: During an interview with Staff 1 (Administrator) on 11/08/24, she reported that not all residents in the memory care facility had a key to their apartment. The need for residents and only appropriate staff to have a key to their units was discussed with Staff 1 (Administrator), Staff 2 (Owner), Staff 4 (RN), and Staff 6 (RCC) on 11/12/24. They acknowledged the findings.

1. All residents have a key in their rooms 2. At time of move ins, apartments will be checked to ensure the apartment key is in place. Resident/family will informed of location. 3. Monthly checks to ensure keys are still placed 4. Admin, RCC

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 C200, C231, C295, C362, C363, C374, C420, C510, C513, C530, C545, and C555.

See POC for C200, C231, C295, C362, C363, C374, C420, C510, C513, C530, C545, and C555

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: Refer to C260, C270, and C310.

See POC for C260, C270, and C310