Print Inspection: RL004871

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 immediately notify the local Senior and People with Disabilities (SPD) office when an incident of abuse or suspected abuse occurred for 1 of 1 sampled resident (#1) who had a resident-to-resident altercation. Findings include, but are not limited to: Resident 3 was admitted to the facility in 04/2025 with diagnoses including Huntington’s disease, Bipolar II and post-traumatic stress disorder. The resident’s record from 04/01/25 through 06/09/25 was reviewed including progress notes, temporary care plans, administrative communication reports, incident reports and incident investigations, and staff were interviewed. The following was identified: The resident experienced resident-to-resident altercations on the following dates: *05/30/25; *06/01/25; *06/05/25; and *06/07/25. There was no documented evidence that the incidents of abuse or suspected abuse were immediately reported to the local SPD office. As of 4:45 pm on 06/12/25, all resident-to-resident altercations for Resident 3 had been reported to the local SPD office. The need to ensure the facility immediately notified the local SPD office when an incident of abuse or suspected abuse occurred was reviewed with Staff 1 and Staff 2 (Day Front Supervisor) on 06/12/25 at 4:45 pm. They acknowledged the findings.

1. The injuries observed on Resident #3 were not initially reported to Adult Protective Services (APS) as required. Upon identification of this oversight during survey, the Administrator immediately contacted APS and submitted the report by 6/12/25. An internal review was completed to determine why the injuries were not recognized as reportable at the time of discovery. Staff involved were re-educated on mandatory reporting protocols, and the Administrator has ensured documentation was updated to reflect both the reporting and subsequent follow-up. 2. To prevent recurrence, all staff will receive re-education on the facility’s abuse reporting policies and procedures, as well as OAR 411-020-0020 and the use of the Oregon “Abuse Decision Tree.” All injuries of unknown origin will now be evaluated within 24 hours by the nursing team. If no clear and documented cause is identified, the incident will be reported to APS without delay. In addition, a designated Supervisor will review all incident reports daily using an Incident Review Log to ensure timely and accurate reporting. The Administrator or designee will review all the Incident Review Log, Incident Reports, and skin observation notes during bi-weekly census meetings to ensure no reportable event is missed. 3. Incident logs, reports, and associated documentation will be audited weekly by the Administrator or designee, and again during the bi-weekly resident census meetings. Any missed or late reports will be logged and tracked for compliance oversight. 4. The Administrator is responsible for ensuring timely abuse reporting and monitoring compliance with the abuse reporting protocol. This includes reviewing all injuries of unknown origin, verifying whether timely reports were submitted, and ensuring that follow-up documentation is complete and accurate.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by:

OAR 411-054-0036 (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' needs and provided clear direction to staff regarding the delivery of services for 2 of 4 sampled residents (#s 2 and 3) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 04/2025 with diagnoses including Huntington’s disease, Bipolar II and post-traumatic stress disorder. The resident’s most current service plan available to staff, dated 05/01/25, and temporary care plans dated 05/01/25 through 06/09/25, were reviewed, the resident was observed, and the resident and staff were interviewed. The resident was noted to have difficulty swallowing, a history of choking, and required a mechanical soft diet texture. The resident’s service plan was not reflective of the resident’s needs and preferences and/or failed to provide clear direction to staff in the following areas: *Mechanical soft diet texture, including provision of snacks; *Use of straw with all drinks; *Use of key; *Pain and non-pharmacological interventions; *How to respond if resident refused to comply with diet texture; *How to respond if resident refused to comply with instructions to eat in the dining room to reduce risk of choking; and *How to assist the resident if s/he verbalized discomfort being around another resident. The need to ensure service plans were reflective of the resident’s needs and provided clear direction to staff regarding the delivery of services was reviewed with Staff 1 (Administrator) and Staff 2 (Day Front Supervisor) on 06/12/25 at 4:45 pm. They acknowledged the findings. 2. Resident 2 moved into the community in 12/2018 with diagnoses including paranoid schizophrenia, traumatic brain injury, and unspecified dementia with behavioral disturbance. The resident’s service plan dated 06/05/25 was reviewed, observations were made, and staff interviews were conducted. The resident's service plan was not reflective of the resident’s needs and did not provide clear direction to staff regarding the delivery of services including the who, what, when, how, and how often services shall be provided in the following areas: * Diet texture; * Assistance with meals; * Adaptive cup use; and * Activity preference of tabletop mirror in front of resident at meals, during tabletop activities, and when awake in bed. On 06/12/25, the need to ensure service plans were reflective of the residents’ needs and provided clear direction to staff was discussed with Staff 1 (Administrator). She acknowledged the findings.

1. The service plan for Resident #3 has been revised to provide detailed, clear, and specific direction to staff. Updates include mechanical soft diet texture with clear instruction for snacks, mandatory use of a straw with all drinks, protocols regarding key use, detailed pain assessment procedures including non-pharmacological interventions, instructions for staff response if the resident refuses to follow diet texture requirements or refuses to eat in the dining room, and staff guidance on supporting the resident when verbalizing discomfort regarding other residents. All updates were completed by the Resident Care Manager (RCM) and verified by the Administrator. 2. All care managers and nursing staff responsible for service plan development are being re-educated on OAR 411-054-0036, emphasizing person-centered planning and the need for clear, actionable staff directions that reflect individual resident needs and preferences. A "Service Plan Review Checklist" has been implemented to ensure that all required elements (who, what, when, how, and how often) are addressed. Interdisciplinary team meetings will now be required following any significant change of condition to ensure collaboration in plan updates. 3. The RCM will perform weekly spot checks on randomly selected service plans and their corresponding daily care logs to ensure accuracy, consistency, and staff adherence. The Administrator or designee will conduct weekly audits of at least three resident service plans until 08/11/2025. This will verify clarity, completeness, and compliance. Thereafter, all service plans will be reviewed quarterly as required by OAR 411-054-0036(4). 4. The RCM is responsible for ensuring that each service plan is developed and maintained accurately and effectively. The Administrator holds ultimate oversight for ongoing monitoring and adherence to the revised protocols and auditing schedule. 1. The service plan for Resident #2 has been updated to include specific directions regarding diet texture, required assistance with meals, adaptive cup use, and the resident's activity preference of having a tabletop mirror during meals, tabletop activities, and when awake in bed. These additions ensure the service plan provides clear and comprehensive guidance for staff and reflects the resident’s personal preferences and support needs. 2. All care managers and nursing staff responsible for service plan development are being re-educated on OAR 411-054-0036, emphasizing person-centered planning and the need for clear, actionable staff directions that reflect individual resident needs and preferences. A "Service Plan Review Checklist" has been implemented to ensure that all required elements (who, what, when, how, and how often) are addressed. Interdisciplinary team meetings will now be required following any significant change of condition to ensure collaboration in plan updates. 3. The RCM will perform weekly spot checks on randomly selected service plans and their corresponding daily care logs to ensure accuracy, consistency, and staff adherence. The Administrator or designee will conduct weekly audits of at least three resident service plans until 08/11/2025. This will verify clarity, completeness, and compliance. Thereafter, all service plans will be reviewed quarterly as required by OAR 411-054-0036(4). 4. The RCM is responsible for ensuring that each service plan is developed and maintained accurately and effectively. The Administrator holds ultimate oversight for ongoing monitoring and adherence to the revised protocols and auditing schedule.

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:

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 determine what resident-specific action or intervention was needed following a short-term change of condition, communicate the determined action or intervention to staff on all shifts, and document weekly progress until the condition resolved for 2 of 4 sampled residents (#s 2 and 3) with short-term changes of condition. Resident 3 expressed ongoing fear to staff, experienced unwanted physical contact, and a fall related to repeat incidents with another resident. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 04/2025 with diagnoses including Huntington’s disease, Bipolar II and post-traumatic stress disorder. The resident’s most current service plan available to staff, dated 05/01/25, and progress notes, temporary care plans, incident reports and incident investigations, dated 04/01/25 through 06/09/25, were reviewed, the resident was observed, and the resident and staff were interviewed. The following was identified: Between 05/06/25 and 05/31/25, staff documented Resident 3 reported to staff on six separate occasions that s/he was being followed by another resident. Resident 3 reported to staff, or staff documented that Resident 3 felt scared and uncomfortable when the other resident would follow him/her or was “invading [Resident 3’s] personal space.” There was no documented evidence the facility determined or documented what intervention was needed and documented weekly progress until the situation resolved. On 06/01/25, Resident 3 reported to staff the same resident had punched him/her in the shoulder. A temporary care plan was placed which instructed staff to redirect the other resident and ensure both residents had an arms’ length distance away from each other. There was no documented evidence the facility monitored Resident 3 for latent bruising, injury or other symptoms following the incident. On 06/02/25, Resident 3 was heard repeatedly telling the other resident to “leave me alone” and “go away.” Staff documented that Resident 3 was “agitated several times over shift” due to the same resident being nearby. On 06/03/25, further incidents between the residents were documented and Resident 3 experienced a fall “when ‘running away’ from [the other resident]”. Staff documented that “[the other resident] had been coming towards [Resident 3] trying to touch [him/her] [and Resident 3] had stated ‘don’t touch me, go away’ and fell onto [his/her] knees.” Resident 3 reported knee pain following the incident. There was no documented evidence the facility monitored the knee pain or resident altercations or developed interventions as a result of the incident. On 06/05/25, staff documented ongoing incidents, including “at times [the other resident] would rub [Resident 3’s] arm or [his/her] back and [Resident 3] would back away. [The other resident] would advance forward as [Resident 3] would back away.” Staff documented that Resident 3 continued to verbalize that the behavior scared him/her and made him/her “very uncomfortable”. Staff documented that “behavior progressed, and [Resident 3] was clearly distressed, evidenced by [shortness of breath] and a grimacing facial expression while trying to avoid [the other resident].” There was no documented evidence the facility monitored Resident 3 related to the incidents above. The facility’s failure to develop and monitor interventions related to the incidents between the two residents resulted in Resident 3 experiencing ongoing fear, unwanted physical contact, and resulted in the resident falling. b. The following short-term changes of condition for Resident 3 lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and/or monitoring at least weekly through resolution: *04/07/25 – Unwitnessed fall; *04/08/25 – Bruise on right knee; *05/03/25 – Unwitnessed fall with redness to knee; *05/07/25 – New medication, diclofenac gel; *05/12/25 – Vomiting; *05/14/25 – Choking; *05/30/25 – Resident to resident altercation involving unsampled resident; and *06/03/25 – Vomiting. The need to ensure the facility determined and documented what action or interventions were needed for short-term changes of condition, communicated the interventions to staff on all shifts and monitored the short-term changes of condition at least weekly through resolution was reviewed with Staff 1 (Administrator) and Staff 2 (Day Front Supervisor) on 06/12/25 at 4:45 pm. They acknowledged the findings. 2. Resident 2 moved into the community in 12/2018 with diagnoses including paranoid schizophrenia, traumatic brain injury, and unspecified dementia with behavioral disturbance. A review of the resident's progress notes dated 03/09/25 through 06/09/25 identified the following short-term changes of condition: * 04/08/25 – “slight swelling noted on right ankle and redness noted on resident right outer calf area”; * 04/08/25 – ingestion of lotion; * 04/23/25 - “slight swelling to right leg”; and * 04/26/25 – “severe pain in [his/her] abdomen area and [his/her] abdomen is very hard to the touch.” There was no documented evidence the resident's changes of condition were monitored, with at least weekly documentation through resolution. An interview with Staff 7 (LPN) on 06/10/25 verified the lack of documented monitoring for the resident's changes of condition. The need for staff to document monitoring of resident changes of condition at least weekly was discussed with Staff 1 (Administrator) on 06/12/25. She acknowledged the findings.

1. Immediate interventions were implemented to address Resident #3's ongoing fear, unwanted physical contact, and fall risk related to altercations. A structured care approach has been developed to include staff redirection of other residents, enforcement of physical distancing, and immediate emotional support when distress is observed. Additionally, historical short-term changes of condition, including multiple falls, bruising, vomiting, medication changes, choking, and peer altercations, have been retrospectively reviewed. Any issues not fully resolved now have active intervention strategies and are being monitored weekly until resolution. 2. All care staff will be retrained on the requirements of OAR 411-054-0040, with a focus on distinguishing between short-term and significant changes of condition. The training will cover documentation procedures, resident-specific interventions, shift-to-shift communication, and the necessity of weekly monitoring until resolution. A "Short-Term Change of Condition Tracking Form" has been implemented to record each incident, outline the corresponding action or intervention, verify that information is communicated to staff on all shifts (with shift sign-off), and document weekly progress notes. Daily shift reports now explicitly include updates on residents with active short-term changes of condition to maintain continuity of care. 3. Weekly rounds will be conducted by the LPN, RN, or designated supervisor to monitor residents with active short-term conditions. The LPN, RN, and/or Administrator will perform weekly audits of the "Short-Term Change of Condition Tracking Forms" until 08/11/2025. Thereafter, monthly audits of a randomized sample of resident records will be conducted to ensure system-wide compliance with monitoring protocols and documentation standards. 4. The LPN or RN is responsible for daily monitoring and implementation of the system. The Administrator will ensure oversight of the process, including weekly audits and staff compliance. 1. For Resident #2, short-term changes of condition, including ankle swelling, lotion ingestion, leg swelling, and abdominal pain, have been reviewed and addressed. Resident-specific interventions have been developed and implemented, and monitoring logs have been initiated with weekly documentation. These interventions ensure consistent tracking and follow-through until each issue is fully resolved. 2. All care staff will be retrained on the requirements of OAR 411-054-0040, with a focus on distinguishing between short-term and significant changes of condition. The training will cover documentation procedures, resident-specific interventions, shift-to-shift communication, and the necessity of weekly monitoring until resolution. A "Short-Term Change of Condition Tracking Form" has been implemented to record each incident, outline the corresponding action or intervention, verify that information is communicated to staff on all shifts (with shift sign-off), and document weekly progress notes. Daily shift reports now explicitly include updates on residents with active short-term changes of condition to maintain continuity of care. 3. Weekly rounds will be conducted by the LPN, RN, or designated supervisor to monitor residents with active short-term conditions. The LPN, RN, and/or Administrator will perform weekly audits of the "Short-Term Change of Condition Tracking Forms" until 08/11/2025. Thereafter, monthly audits of a randomized sample of resident records will be conducted to ensure system-wide compliance with monitoring protocols and documentation standards. 4. The LPN or RN is responsible for daily monitoring and implementation of the system. The Administrator will ensure oversight of the process, including weekly audits and staff compliance.

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:

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 residents' MARs were accurate and included resident-specific parameters and instructions for PRN medications for 1 of 4 sampled residents (#2) whose MARs were reviewed. Findings include, but are not limited to: Resident 2 moved into the community in 12/2018 with diagnoses including paranoid schizophrenia, traumatic brain injury, and unspecified dementia with behavioral disturbance. Resident 2's 05/01/25 through 06/09/25 MAR and corresponding prescriber orders were reviewed, and staff were interviewed. The following was identified: a. The following PRN psychotropic medications lacked resident-specific parameters, including sequential order of use: * Lidoderm lorazepam topical cream – apply one ml topically to skin every four hours as needed for anxiety/agitation: refusing oral medications, refusing care yelling, crying. Give two hours away from PRN lorazepam tablet. * Lorazepam 1 mg tab – take one tablet by mouth every two hours as needed for terminal nausea/agitation/anxiety: refusal of care, yelling, combative, crying. Give two hours away from PRN topical lorazepam. * Olanzapine 2.5 mg tabs – give one 2.5 mg tab by mouth every six hours as needed for combativeness, care refusal, yelling. The resident was administered all three PRN medications multiple times in May and June. b. The signed prescriber order for PRN Lidoderm lorazepam cream stated, “No change to tablet lorazepam; use tablets if accepting”. This had not been transcribed onto the MAR. The need to ensure MARs were accurate, including providing resident-specific parameters and instructions for PRN medications, was reviewed with Staff 1 (Administrator) and Staff 7 (LPN) on 06/12/25. They acknowledged the findings.

1. The Medication Administration Record (MAR) for Resident #2 has been immediately updated to accurately reflect all resident-specific parameters and sequential instructions for the following PRN psychotropic medications: Lidoderm lorazepam topical cream, lorazepam 1 mg tablet, and olanzapine 2.5 mg tablet, as ordered by the prescriber. The specific directive, “No change to tablet lorazepam; use tablets if accepting,” has been transcribed onto the MAR for the Lidoderm lorazepam cream. These updates ensure clarity regarding the proper sequence of administration and full adherence to the prescriber’s intent. 2. All Medpassers, RCMs, and Nurses will receive immediate in-service training focused on: · Accurate transcription of prescriber orders onto the MAR; · Resident-specific PRN parameters and sequential administration requirements; · Documentation requirements for PRN psychotropic medication administration in compliance with OAR 411-054-0055(2). A comprehensive audit of all PRN medication orders for all residents will be completed and compared to their corresponding MARs to verify accuracy and completeness. A “PRN Medication Audit Tool” has been developed and will be used by the LPN, RN, Supervisor, or designee to verify transcription accuracy before administering any new PRN medication. Additionally, a dual-verification process will be implemented for all new PRN psychotropic medications, requiring both an LPN and RN to confirm transcription against the original prescriber order. The facility’s medication reconciliation protocol for all resident admissions and readmissions has been updated to include a dedicated step verifying PRN medication parameters and sequential instructions on the MAR. 3. The LPN, RN, or designee will conduct weekly audits of at least five resident MARs through 08/11/2025, with a specific focus on PRN psychotropic medication documentation. Following this corrective period, monthly audits of randomized MAR samples will continue to ensure ongoing compliance and sustained accuracy. 4. The RN will be responsible for implementing and maintaining MAR accuracy, utilizing the audit tool, and ensuring all prescriber instructions are appropriately transcribed. The Administrator will provide overarching oversight of the process, verify staff competency through training completion and audit review, and ensure corrective actions are carried out effectively.

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: