Print Inspection: RL007443

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 short-term changes of condition were monitored through resolution for 1 of 2 sampled residents (#2). Findings include, but are not limited to: Resident 2 moved into the facility in 09/2024 with diagnoses including bipolar disorder and dementia. The resident’s clinical record, including progress notes from 07/16/25 through 10/17/25 were reviewed, observations were made, and staff were interviewed during the survey. The resident was noted to have experienced the following short-term changes of condition: * 07/29/25 - Refusal of morning medications, which included: - Eliquis (for atrial fibrillation); - Levetiracetam (for unspecified seizure disorder); - Lisinopril (for hypertension); - Memantine (for dementia); - Metformin (for type 2 diabetes mellitus); and - Metoprolol tartrate (for hypertension). * 09/07/24 - Elopement; and * 10/03/25 - Return from an emergency department visit following multiple days of diarrhea. There was no documented evidence these short-term changes of condition were monitored, with progress noted at least weekly, to resolution. On 10/22/25 at 12:40 pm, Staff 2 (RN) confirmed the identified changes of condition, and she acknowledged the lack of documented monitoring through resolution. Staff 2 stated she was new to the facility and in the process of establishing communication protocols between herself and the med techs. The need to ensure the facility monitored short-term changes of condition through resolution, with progress documented at least weekly, was discussed with Staff 1 (Administrator), Staff 2, and Staff 3 (Facilities Operations Manager) on 10/22/25. They acknowledged the findings. On 10/22/25 at 12:40 pm, Staff 2 (RN) confirmed the identified changes of condition, and she acknowledged the lack of documented monitoring through resolution. Staff 2 stated she was new to the facility and in the process of establishing communication protocols between herself and the med techs. The need to ensure the facility monitored short-term changes of condition through resolution, with progress documented at least weekly, was discussed with Staff 1 (Administrator), Staff 2, and Staff 3 (Facilities Operations Manager) on 10/22/25. They acknowledged the findings.

This deficiency will be corrected by performing a full audit of resident records over the past 60 days; it will be conducted to identify any additional residents with a short-term change of condition lacking proper documentation or follow-up. The administrator and RN have both taken change of condition courses provided on NuresLearning. A Change of Condition Tracking Tool will be introduced to monitor compliance. Monthly audits will be conducted by the Administrator for the next 6 months to ensure ongoing compliance. If trends are identified, corrective actions will be implemented immediately.

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 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure physician's orders were carried out as prescribed for 2 of 2 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 09/2012 with diagnoses including seizure disorder and schizophrenia. Review of Resident 1’s MAR, dated 10/01/25 through 10/20/25, and current physician's orders, dated 08/04/25, identified the following: * Propranolol was ordered to be administered two tablets by mouth twice daily, with parameters to not administer if heart rate was less than 60 beats per minute. The MAR lacked documented evidence the resident’s heart rate was taken prior to the medication being administered 39 times from 10/01/25 to 10/20/25. The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Administrator), Staff 2, and Staff 3 (Facilities Operations Manager) on 10/22/25. They acknowledged the findings. 2. Resident 2 moved into the facility 09/2024 with diagnoses including bipolar disorder and dementia. Review of Resident 2’s MAR, dated 10/01/25 through 10/20/25, and current physician's orders, dated 08/04/25, identified the following: * Cetirizine order changed to PRN, starting 05/14/25. The MAR lacked documented evidence the medication was changed to PRN, as the medication continued to be administered as scheduled, one tablet daily, 15 times from 10/01/25 to 10/20/25. During an interview on 10/20/25 at 3:10 pm, Staff 2 (RN) confirmed the cetirizine medication was not changed to PRN per the physician order. The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Administrator), Staff 2, and Staff 3 (Facilities Operations Manager) on 10/22/25. They acknowledged the findings.

This deficiency will be corrected by performing a full audit of resident medication records over the past 60 days; this will be conducted to identify all physicians orders are accurately transcribed on the MAR. A Medication change tracking tool will be introduced to monitor compliance. Weekly audits will be completed by the administrator to maintain compliance.

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

OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to complete a quarterly evaluation of the resident’s ability to safely self-administer medications for 1 of 1 sampled resident (# 1) who chose to self-administer their medications. Findings include, but are not limited to: Resident 1 moved into the facility in 09/2012 with diagnoses including seizure disorder and schizophrenia. Review of Resident 1’s 10/1/25 through 10/20/25 MAR noted the following medications were not administered by the facility: * Fluticasone nasal spray; and * Systane eyedrops. There was no documented evidence an evaluation of Resident 1's ability to administer their own medications had been completed. During an interview on 10/20/25 at 3:10 pm, Staff 2 (RN) confirmed there was no evaluation completed for self-administration of medication for Resident 1. The need to ensure the facility updated the self-administration of medications evaluation was discussed with Staff 1 (Administrator), Staff 2, and Staff 3 (Facilities Operations Manager) on 10/22/25. They acknowledged the findings.

A self administration of medications evaluation has been completed for this resident by the facility RN. Upon a resident move in, the Administrator and RN will work together to determine if a resident has any self administrating medications. If a resident does have self administering medications, the RN will conduct an evaluation monthly. The administrator will conduct an audit monthly to ensure the assessment is completed by the RN.

OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order. This Rule is not met as evidenced by:

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 interview and observation, it was determined the facility failed to ensure the environment was free from unpleasant odors and its interior surfaces were clean and in good repair. Findings include, but are not limited to: The facility was toured with Staff 1 (Administrator) and Staff 3 (Facility Operations Manager) on 10/21/2025 at 1:50 pm. The following was noted: * A pervasive odor that did not dissipate throughout the survey in the hallway between rooms one through five; * Shelves, tables, and window tracks throughout the facility had brown and grey debris on the surfaces; * A chair and couch in the living room area had tears on the seating surfaces; * Carpet throughout the facility had brown and black stains and carpet was torn near the front entryway; and * Wooden tables in the dining area had scuffs and gouges on the edges, making the surfaces uncleanable. The need to ensure that the facility was free from unpleasant odors and its interior surfaces were clean and in good repair was reviewed with Staff 1 and Staff 3 on 10/22/2025. They acknowledged the findings.

A new cleaner has been purchased to remove the odor smell. We will also be doing weekly carpet cleanings to reduce all odor smells. A new comprehensive cleaning schedule has been implemented to ensure the facility is free of dust and debris. The couch and chair with a tear have been removed, and will be replaced. The facility has implemented weekly carpet cleanings, and a more comprehensive schedule with professional carpet cleanings. The tables in the dining area are currently being replaced with new ones. The administrator and Maintenance Director will conduct frequent walk throughs of the facility to ensure the facility is in good repair and free of odors. The facility administrator and maintenance director will be responsible to ensure these items are monitored and completed.

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:

OAR 411-054-0200 (5) Resident Units (5) RESIDENT UNITS. Resident units may be limited to a bedroom only, with bathroom facilities centrally located off common corridors. Each resident unit shall be limited to not more than two residents.(a) Resident units must have a lockable door with lever type handles, effective 01/15/2017. This applies to all existing and new construction.(b) For bedroom units, the door must open to an indoor, temperature controlled common-use area or common corridor. Residents may not enter a room through another resident's bedroom.(c) Resident units must include a minimum of 80 square feet per resident, exclusive of closets, vestibules, and bathroom facilities and allow for a minimum of three feet between beds;(d) All resident bedrooms must be accessible for individuals with disabilities and meet the requirements of the building codes. Adaptable units are not acceptable.(e) A lockable storage space (e.g., drawer, cabinet, or closet) must be provided for the safekeeping of a resident's small valuable items and funds. Both the administrator and resident may have keys.(f) WARDROBE CLOSET. A separate wardrobe closet must be provided for each resident's clothing and personal belongings. Resident wardrobe and storage space must total a minimum volume of 64 cubic feet for each resident. The rod must be adjustable for height or fixed for reach ranges per building codes. In calculating useable space closet height may not exceed eight feet and a depth of two feet.(g) WINDOWS.(A) Each sleeping and living unit must have an exterior window that has an area at least one-tenth of the floor area of the room. A CF must have at least one exterior window with a minimum size of 8 square feet per resident.(B) Unit windows must be equipped with curtains or blinds for privacy and control of sunlight.(C) Operable windows must be designed to prevent accidental falls when sill heights are lower than 36 inches and above the first floor.(h) RESIDENT UNIT BATHROOMS. If resident bathrooms are provided within a resident unit, the bathroom must be a separate room and include a toilet, hand wash sink, mirror, towel bar, and storage for toiletry items. The bathrooms must be accessible for individuals who use wheelchairs.(i) UNIT KITCHENS. If cooking facilities are provided in resident units, cooking appliances must be readily removable or disconnect-able and the RCF must have and carry out a written safety policy regarding resident-use and nonuse. A microwave is considered a cooking appliance. This Rule is not met as evidenced by: Based on interview and observation, it was determined the facility failed to ensure the environment was free from unpleasant odors and its interior surfaces were clean and in good repair. Findings include, but are not limited to: The facility was toured with Staff 1 (Administrator) and Staff 3 (Facility Operations Manager) on 10/21/2025 at 1:50 pm. The following was noted: * A pervasive odor that did not dissipate throughout the survey in the hallway between rooms one through five; * Shelves, tables, and window tracks throughout the facility had brown and grey debris on the surfaces; * A chair and couch in the living room area had tears on the seating surfaces; * Carpet throughout the facility had brown and black stains and carpet was torn near the front entryway; and * Wooden tables in the dining area had scuffs and gouges on the edges, making the surfaces uncleanable. The need to ensure that the facility was free from unpleasant odors and its interior surfaces were clean and in good repair was reviewed with Staff 1 and Staff 3 on 10/22/2025. They acknowledged the findings.

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 that it provided a manually operated call system in each toilet and bathing facility used by residents and visitors. Findings include, but are not limited to: Observations of the facility interior on 10/22/25 revealed the bathrooms in resident rooms four and eight and common area shower rooms lacked manually operated call systems. In an interview on 10/22/2025 with Staff 1 (Administrator) and Staff 3 (Facility Operations Manager), Staff 3 confirmed all of the facility’s toilet and bathing facilities lacked a manually operated call system. The need to provide a manually operated emergency call system in each toilet and bathing facility used by residents and visitors was reviewed with Staff 1 and Staff 3 on 10/22/25. They acknowledged the findings.

A call system has been ordered, this will include pull stations in all of the bathrooms and shower rooms. The system will be installed as soon as it arrives. The system will be monitored daily to ensure it is in working order. The administrator and Maintenance director will ensure the system gets installed promptly, and that it is working daily.

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: