Print Inspection: RL012388

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 1 of 1 sampled resident (#3) whose ADL care was observed. Findings include, but are not limited to: Resident 3 was admitted to the facility in 04/2023 with diagnoses including paranoid schizophrenia and diabetes. During an ADL observation on 06/10/26 at 1:05 pm, the following was noted: * Staff 12 (CG) provided incontinence care for Resident 3; * Staff 12 started to remove Resident 3’s soiled brief without performing hand hygiene, then placed the soiled brief on the floor; * Staff 12 removed a clean brief from a bag, placed it on the chair near the resident, and then picked up the soiled brief from the floor, and disposed of it in a trash can in the bathroom; and * Staff 12 returned and applied the clean brief without performing hand hygiene from dirty to clean tasks and did not utilize gloves throughout the incontinence care. The observation and the need to implement effective methods of infection control were discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (Health Services Coordinator/LPN), Staff 7 (District RN), and Staff 8 (Regional Director of Operations) on 06/10/26 at 3:50 pm. They acknowledged the findings.

1. Staff 12 was re-educated on proper infection control measures including glove use on 6/26/26. 2. Current direct care staff were re-educated on hand hygiene, infection control practices and glove use on 6/23/26 3. Routine observations of resident care will be conducted twice weekly for 30 days, then weekly for 60 days to validate use of proper infection control measures. 4. Executive Director, Health & Wellness Directoror designee is responsible for this plan of correction.

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 medication orders were carried out as prescribed for 3 of 6 sampled residents (#s 3, 4, and 5) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 04/2023 with diagnoses including paranoid schizophrenia and diabetes. The resident’s 05/01/26 through 06/08/26 MARs, current physician’s orders, and clinical record were reviewed. The following was identified: Resident 3 had a physician’s order to change Dexcom (a continuous blood sugar monitor) every 10 days. Documentation on the MAR had a code of 18 (indicating other/see progress notes) on three occasions between May and June. There was no documentation in the progress notes to verify if the device was changed as ordered and no exception was documented. On 06/10/26 at 3:30 pm, Staff 2 (RN) verified there was no documented evidence to indicate if the device was changed as ordered. The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (Health Services Coordinator/LPN), Staff 7 (District RN), and Staff 8 (Regional Director of Operations) on 06/10/26 at 3:50 pm. They acknowledged the findings. No additional information was received. 2. Resident 4 was admitted to the facility in 03/2024 with diagnoses including dementia and diabetes. The resident's 05/01/26 through 06/08/26 MARs, current prescriber orders, and clinical record were reviewed. The following was identified: a. Resident 4 had an order to apply a lidocaine 5% patch topically, remove after 12 hours as needed for pain. The resident received the PRN order on 4 occasions between May and June; however, there was no indication the patch was removed per prescriber's orders. On 06/10/26 at 12:45 pm, Staff 1(ED) and Staff 2(RN) confirmed the MAR or progress notes did not provide evidence the patch was removed 12 hours following administration. b. Resident 4 had an order dated 01/19/2026 to check blood sugar three times daily for blood sugar monitoring. The order was not transcribed into the MAR; therefore, the resident’s blood sugar was not checked as prescribed. On 06/10/26 at 1:30pm Staff 7(District RN) confirmed the order for blood sugar check three times daily was not transcribed to MAR. c. Resident 4 had a physician's order to obtain the resident’s weight daily, directing staff to notify the physician if the resident gained two pounds in two days or five pounds in a week. There was no documented evidence the facility had notified the physician when the resident gained two or more pounds in two days and/or five pounds in one week on three occasions. The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (Health Services Coordinator/LPN), Staff 7 (District RN) and Staff 8 (Regional Director of Operations) on 06/10/26 at 3:50 pm. They acknowledged the findings. No additional information was received. 3. Resident 5 moved into the facility in 01/2026 with diagnosis of congestive heart failure. The resident’s 05/01/26 through 06/08/26 MARs, current prescriber orders, and clinical record were reviewed. The following was identified: Resident 5 had a physician's order to obtain the resident’s weight daily, directing staff to notify the physician if the resident gained two or more pounds overnight or five pounds in a week. During an interview on 06/09/26 at 1:45 pm, Staff 10 (MT) confirmed the facility’s process to notify the physician if the resident gained more than two pounds in overnight was to fax the physician’s office, and then document the fax was sent in the progress notes. There was no documented evidence the facility had notified the physician when the resident gained two or more pounds overnight on five occasions. The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 2 (RN), Staff 7 (District RN), Staff 8 (Regional Director of Operations), and Staff 9 (MT) on 06/10/26 at 1:45 pm. They acknowledged the findings.

1.The medication administration record for Resident #3, 4 and 5 have been reconciled with physician orders and revised as applicable. Provider notification has occurred as indicated. 2. Remaining resident medication administration records will be reviewed for accuracy. Additional education will be provided to medication technician staff on folowing physician orders, documentation processes including documenting exceptions to orders and physician notification when results are outside parameters. 3. Medication orders with documented exceptions will be reviewed daily in conjunction with clinical review meeting at minimum of 3 times per week. Executive Director or designee will conduct random review of medication admninistration records and associate documentation weekly for 60 days to monitor ongoing compliance. 4. Executive Director, Health & Wellness Director or designee is responsible for this plan of correction.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused to consent to orders for 3 of 3 sampled residents (#s 3, 4, and 5) who had documented medication or treatment refusals. Findings include, but are not limited to: 1. Resident 5 moved into the facility in 01/2026 with diagnosis of congestive heart failure. The resident's 05/01/26 through 06/08/26 MARs, current prescriber orders, and clinical record were reviewed. The following was identified: Staff documented the resident refused nystatin powder (for rash) on 11 occasions in May. During an interview on 06/09/26 at 1:40 pm, Staff 10 (MT) confirmed the facility was to inform the prescriber of every medication or treatment refusal via a fax. However, there was no documented evidence staff notified the prescriber of Resident 5’s refusals. The need to notify the practitioner when a resident refused to consent to an order was discussed with Staff 1 (ED), Staff 2 (RN), Staff 7 (District RN), Staff 8 (Regional Director of Operations), and Staff 9 (MT) on 06/10/26 at 1:45 pm. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 04/2023 with diagnoses including paranoid schizophrenia and diabetes. The resident's 05/01/26 through 06/08/26 MARs, current prescriber orders, and clinical record were reviewed. The following was identified: Staff documented the resident refused the following treatments; * Bag balm ointment for (dry skin) on 34 occasions in May and 10 occasions in June; and *Desitin cream for (irritated itch or rash) on 13 occasions in May and four occasions in June. During an interview on 06/10/26 at 1:00 pm, Staff 9 (MT) confirmed the facility was to inform the prescriber of every medication or treatment refusal via a fax. However, there was no documented evidence staff notified the prescriber of Resident 3’s refusals. The need to notify the practitioner when a resident refused to consent to an order was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (Health Services Coordinator/LPN), Staff 7 (District RN) and Staff 8 (Regional Director of Operations) on 06/10/26 at 3:50 pm. They acknowledged the findings. 3. Resident 4 was admitted to the facility in 03/2024 with diagnoses including dementia and diabetes. The resident's 05/01/26 through 06/08/26 MARs, current prescriber orders, and clinical record were reviewed. The following was identified: Staff documented the resident refused the following treatment; * Nystatin powder for (rash) on 15 occasions in May and five occasions in June. During an interview on 06/10/26 at 1:00 pm, Staff 9 (MT) confirmed the facility was to inform the prescriber of every medication or treatment refusal via a fax. However, there was no documented evidence staff notified the prescriber of Resident 4’s refusals. The need to notify the practitioner when a resident refused to consent to an order was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (Health Services Coordinator/LPN), Staff 7 (District RN), and Staff 8 (Regional Director of Operations) on 06/10/26 at 3:50 pm. They acknowledged the findings.

1. The primary care provider for Resident #3, 4 and 5 have been notiifed of medication refusals in May and June. 2. Remaining resident medication administration records have been reviewed for the last 30 days to assure physician notification for refusals. Medication technicians will be re-educated on requirements of notifying providers of refusals. 3. Medication and treatment refuals will be reviewed daily in conjunction with clinical review meeting at minimum of 3 times per week to assure physician notification. Executive Director or designee will conduct random review of medication admninistration records and associate documentation weekly for 60 days to monitor ongoing compliance. 4. Executive Director, Health & Wellness Director or designee.

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 which included resident-specific parameters for 1 of 6 sampled residents (# 4) whose MARs were reviewed. Findings include, but are not limited to: Resident 4 was admitted to the facility in 03/2024 with diagnoses including dementia and diabetes. The resident's 05/01/26 through 06/08/26 MARs, current prescriber orders, and clinical record were reviewed. The following was identified: The following PRN medications for pain lacked the sequential order for administration: * Celebrex; * Diclofenac; * Hydrocodone/Acetaminophen; * Lidoderm patch (for pain); and *Acetaminophen (for pain). Resident 4 was administered Celebrex on seven occasions in May and two occasions in June, hydrocodone/acetaminophen on three occasions in May and four occasions in June and Lidoderm patch once in May and three occasions in June. During an interview on 06/10/26 at 3:30 pm, Staff 2 (RN) confirmed the lack of specific parameters for the PRN medications used for the same diagnosis. The need to ensure MARs were accurate and included resident specific parameters for PRN medications used for the same diagnosis was discussed with Staff 1 (ED), Staff 2, Staff 3 (Health Services Coordinator/LPN), Staff 7 (District RN) and Staff 8 (Regional Director of Operations) on 06/10/26 at 3:50 pm. They acknowledged the findings.

1. The medication administration record for Resident #4 has been updated to reflect nursing clarification and instruction for as needed medications. 2. The medication administration records for remaining residents will be reviewed to assure nursing clarification and instruction are present for as needed medications. Medication technicians will be educated on referencing these instructions prior to administering as needed medications. 3. Nursing clarification and instruction will be added in conjunction with the transcription order review process. Executive Director or designee will conduct a random review of medication administration records weekly for 60 days to monitor ongoing compliance. 4. Executive Director and Health & Wellness Director/RN are responsible for this plan of correction.

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 9, 10, 11, and 16) completed fire safety training prior to beginning job responsibilities. Findings include, but are not limited to: Staff training records were reviewed on 06/08/26 at 1:24 pm with Staff 6 (Business Office Manager) and the following was identified: There was no documented evidence Staff 9 (MT) hired on 04/06/26, Staff 10 (MT) hired on 04/27/26, Staff 11 (CG) hired on 04/09/26, or Staff 16 (Housekeeper) hired on 04/20/26 completed a fire safety training prior to beginning their job responsibilities. On 06/10/26 at 1:20 pm Staff 1 (ED), Staff 2 (RN), Staff 3 (Health Services Coordinator/LPN), Staff 7 (District RN) and Staff 8 (Regional Director of Operations) acknowledged fire safety training had not been performed with staff prior to beginning job responsibilities. ?

1. Staff # 9, 10, 11 and 16 have completed fire safety training. 2. Remaining staff training files will be reviewed to validate completion of pre-service orientation topics as described in rule. Business office coordinator was educated on pre-service training requirements per rule and associated community orientation training documents. Newly hired staff training compliance will be discussed in manager meeting weekly in order to assure pre-service requirements are met before job specific training begins. 3. Executive Director will conduct random audits of pre-service training documentation weekly for 30 days and monthly for 60 days. 4. Executive Director, Business Office Coordinator or designee are responsible for this plan of correction.

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 ensure fire and life safety instruction was provided to staff on alternate months from fire drills and written fire drill records included all required elements according to the Oregon Fire Code (OFC). The findings include, but are limited to: Fire drill records from 12/2025 to 05/2026 were reviewed with Staff 5 (Maintenance Supervisor) on 06/09/26 at 12:30 pm. The following was identified: a. Fire drill records lacked one or more of the following required components: * The time of the fire drill; * The location of the simulated fire origin; * Escape route use; * Evacuation time period; and * The number of occupants evacuated. b. The facility lacked documented evidence fire and life safety instructions was provided to staff on alternate months of fire drills. The need to ensure fire and life safety instruction was provided to staff on alternating months from fire drills and written fire drill records included all required elements according to the OFC was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (Health Services Coordinator/LPN), Staff 7 (District RN) and Staff 8 (Regional Director of Operations) on 06/10/26 at 1:20 pm. She acknowledged the findings.

1. Education on rule requirements was completed with Maintenance Supervisor on 6/29/26. 2. Fire drills check list will be updated to include all of the required components. 3. Executive Director or designee will audit fire drill and education documentation monthly for 3 months then quarterly thereafter. 4. Executive Director, Maintenance Supervisor or designee are responsible for this plan of correction.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. 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 reinstruction to residents at least annually. Findings include, but are not limited to: Fire and life safety records were reviewed with Staff 5 (Maintenance Director) on 06/09/26 at 12:30 pm. There was no documented evidence residents were provided fire safety reinstruction annually. On 06/09/26 at 1:20 pm, the need to provide fire and life safety reinstruction to residents at least annually was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (Health Services Coordinator/LPN), Staff 7 (District RN) and Staff 8 (Regional Director of Operations). Staff 1 acknowledged the need to provide the residents with fire and life safety training.

1. Fire Education will be provided to resident during care conference annually. 2. Executive Director and Maintenance Supervisor have reviewed rule requirements for fire and life safety instruction to residents at least annually. Fire and life safety instruction will be provided to resident during care conference annually. 3. Executive Director or designee will audit service plan documentation monthly for 3 months then quarterly thereafter. 4. Executive Director, Maintenance Supervisor or designee is responsible for this plan of correction