Print Inspection: RL012627

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 observation, interview, and record review, it was determined the facility failed to determine and document what action or intervention was needed for short-term changes of condition, communicate the action or intervention to staff on each shift and document progress through resolution, and failed to monitor residents consistent with evaluated needs for 2 of 2 sampled residents (#s 3 and 6) who were reviewed for skin issues. Findings include, but are not limited to: 1. Resident 3 was admitted into the facility in 11/2019 with diagnoses including transient cerebral ischemic attack (stroke) and scabies. The resident's clinical record, including progress notes dated 03/26/26 through 06/22/26, service plan addendums (SPAs), and facility incident reports were reviewed, observations were made, and interviews with facility staff were conducted between 06/22/26 and 06/25/26. a. From 05/01/26 to 06/10/26, Resident 3 was identified to have a significant weight loss of 27.9 pounds or 17.73% of his/her total body weight in one month. On 06/24/26 at 9:01 am, Staff 2 (RN/Health Services Director) reported she had seen a decline in the resident’s weight. There was no documented evidence the facility determined and documented what action or intervention was needed for the weight loss, communicated the action or intervention to staff on each shift and monitored the resident with documented progress at least weekly through resolution. b. On 05/21/26 the resident was diagnosed with scabies and throughout the survey, Resident 3 was observed to have a raised red rash on his/her arms, legs, and stomach, and was noted itching his/her arms. On 06/24/26 at 9:25 am, Staff 3 (LPN/Health Services Assistant) reported the resident had a history of reoccurring scabies and currently s/he was at baseline and therefore staff were not directed to monitor the resident’s skin. There was no documented evidence the facility monitored the resident consistent with evaluated needs for the recurrent scabies. c. The resident experienced multiple falls from 05/21/26 to 06/19/26 and the record lacked documented evidence actions or interventions were determined, documented, and communicated to staff and the changes were monitored with weekly progress noted to resolution, for the following: * 05/21/26 – unwitnessed injury fall in the front parking lot; * 06/04/26 – unwitnessed injury fall in the resident’s room; * 06/11/26 – unwitnessed non-injury fall in the resident’s room; * 06/17/26 – unwitnessed non-injury fall in the resident’s room at 12:00 am; * 06/19/26 – unwitnessed non-injury fall in the resident’s room at 12:00 am; * 06/19/26 – unwitnessed non-injury fall in the resident’s room at 7:30 am; and * 06/19/26 – unwitnessed non-injury fall in the resident’s room at 9:50 am. The resident’s service plan instructed staff to remind the resident to use his/her pendant to call for assistance, to use his/her four wheeled walker when ambulating, and to check on the resident at routine intervals throughout the day and night. Documented facility SPAs, dated 06/17/26 and 06/19/26, noted for staff to check on the resident at routine intervals and to remind the resident how to use the call system. On 06/24/26 at 8:28 am, Resident 3 was observed ambulating unsteadily in his/her apartment with a four wheeled walker. On 06/24/26 at 1:50 pm, Staff 3 confirmed there was no additional documentation related to the resident’s multiple falls. d. On 06/24/26 at 8:28 am, Staff 10 (MT) reported Resident 3 had a change in cognition recently and had been exhibiting more behaviors including hallucinations, talking to self, and had been found wandering in the facility’s front and back parking lots. Staff documented the following: * 06/13/26 - Staff saw Resident 3 in the back parking lot and re-directed him/her safely to his/her apartment; * 06/14/26 - Resident appears to be agitated this shift and was mumbling to self; * 06/15/26 - Resident has been very confused this morning; * 06/18/26 - Resident “not at baseline” and “[S/he] was tired and having hallucinations talking to the wall very moody”; and * 06/19/26 - Resident seems a bit confused. There was no documented evidence the facility determined actions or interventions, communicated them to staff, and monitored the above changes with weekly progress noted to resolution. On 06/24/26 at 9:01 am, Staff 2 acknowledged the lack of documentation. The need to ensure the facility determined and documented what action or intervention was needed, communicatee the action or intervention to staff on each shift, and documented progress at least weekly through resolution was reviewed with Staff 1 (Interim ED), Staff 2, and Staff 3 on 06/25/26 at 11:20 am. They acknowledged the findings. 2. Resident 6 was admitted into the facility in 10/2025 with diagnoses including dementia. The resident's clinical record, including progress notes dated 03/23/26 through 06/22/26, service plan addendums (SPAs), and facility incident reports were reviewed, observations were made, and interviews with facility staff were conducted between 06/22/26 and 06/25/26. Resident 6 was seen by an outside provider once weekly for wound care and the outside provider documented the following: * 04/01/26 – “Back wound remains red and open, 2.5 cm x 3 cm”; * 04/09/26 – “Wound to upper back 7 cm x 6.2 cm”; * 04/30/26 – “Ongoing back wound [with] redness 6 cm x 5 cm”; * 05/07/26 – “Patient had wound to back 7 cm x 5.5 cm, not open, stage 1”; * 05/14/26 – “Dressing changed to mid back, ongoing redness, slightly improving 6 cm x 5 cm”; * 06/04/26 – “Wound to back 6 cm x 4.5 cm”; and * 06/11/26 – “Back wound remains red, scant drainage to dressing. 5 cm x 4.5 cm”. On 06/23/26 at 10:13 am, Staff 2 reported she was unaware the resident had a current and ongoing back wound. On 06/24/26 at 9:40 am, Staff 2 completed a skin assessment and noted the resident had two upper back wounds measuring “3cm x 3cm” and “2cm x 2cm”. There was no documented evidence the facility determined and documented what action or intervention was needed for the skin condition, communicated the action or intervention to staff on each shift, and monitored the resident with documented progress through resolution. The need to ensure the facility determined and documented what action or intervention was needed, communicate the action or intervention to staff on each shift, and documented weekly progress through resolution was reviewed with Staff 1 (Interim ED), Staff 2, and Staff 3 on 06/25/26 at 11:20 am. They acknowledged the findings.

Residents 3 and 6 received thorough nursing assessments. Resident 3's significant weight loss, scabies, falls, cognitive and behavioral changes, and overall changes in condition were assessed. This resulted in her being placed on hospice The RN will continue doing weekly sig change notes and monitor weights and any other declines. Resident 6 received a comprehensive skin assessment. Outside wound care notes were reviewed and incorporated into the Service Plan. RN will continue to complete weekly would assessments until resolved. The nurses completed an audit of all current residents with: • significant weight loss; • active wounds or skin conditions; • recent falls; • documented changes in condition; • ongoing monitoring needs. Any resident identified as lacking documented interventions, staff communication, or weekly monitoring had assessments completed, SPAs updated, and appropriate monitoring initiated To ensure timely evaluation, monitoring, and service plan revisions for residents experiencing falls, significant weight changes, skin issues, cognitive changes, infections, behavioral changes, or other significant or short-term changes in condition, these residents will be reviewed during the community's daily clinical meeting, held Monday through Friday to ensure appropriate follow-up, monitoring, and service plan updates are completed as needed. The Executive Director will oversee this process and ensure the daily clinical meetings and tracking system are consistently implemented.

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 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed in a timely manner and documented findings, resident status, and interventions made as a result of the assessment for 1 of 2 sampled residents (#3) who experienced significant changes of condition. Findings include, but are not limited to: Resident 3 was admitted into the facility in 11/2019 with diagnoses including transient cerebral ischemic attack, sepsis, anxiety, and scabies. The resident's clinical record, including the current service plan dated 06/08/26 and progress notes were reviewed, observations were made, and interviews with facility staff were conducted between 06/22/26 and 06/25/26. Facility staff documented the following weights: * 04/01/26 – 157.3 pounds; * 05/01/26 – 157.3 pounds; * 06/10/26 – 129.4 pounds; and * 06/24/26 – 143.1 pounds. From 05/01/26 to 06/10/26, the resident lost a total of 27.9 pounds or 17.73% of his/her total body weight in one month. This constituted a significant change of condition and required an RN assessment. On 06/22/26 at 1:06 pm, Resident 6 was provided a filet of salmon, yellow rice, and whole cauliflower florets and was observed to consume a couple small bites of salmon. The remainder of the meal was observed in the resident’s refrigerator at 2:17 pm. On 06/24/26 at 9:01 am, Staff 2 (RN/Health Services Director) reported she had seen a decline in the resident’s weight and would re-weigh the resident that day. At 9:24 am, Staff 12 (PCA) reported the resident to weigh 143.1 pounds and at 1:10 pm, Staff 2 provided an RN assessment for the resident’s significant weight loss dated 06/24/26. The need to ensure RN assessments were completed timely, and documented findings, resident status, and interventions made as a result of the assessment was reviewed with Staff 1 (Interim ED), Staff 2, and Staff 3 (LPN/Health Services Assistant) on 06/25/26 at 11:20 am. They acknowledged the findings.

Resident 3 received a comprehensive RN assessment addressing the significant weight loss. The assessment included the resident's current status, findings, contributing factors, and interventions, including ongoing weight monitoring, nutritional interventions, provider notification, and Service Plan updates. The RN reviewed all residents with significant changes in condition to ensure timely RN assessments were completed and documented. To prevent recurrence staff were educated on the Change of Condition process and timely RN assessment requirements. The RN will complete weekly audits of significant changes in condition for 90 days to ensure compliance. Nursing team will audit weights weekly. The team will also inspect the scale to ensure that weights are reading accurately. The Executive Director Will ensure the nursing leadership is completing weekly audits of resident's weights.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. 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 observation, interview and record review, it was determined the facility failed to ensure diet orders were carried out as prescribed for 2 of 2 sampled residents (#s 2 and 6) who were prescribed a modified diet texture. Findings include, but are not limited to: 1. Resident 2 was admitted into the facility in 07/2022 with diagnoses including cerebrovascular accident (stroke) and dysphagia (difficulty swallowing). The resident’s 06/01/26 through 06/22/26 MAR, current physician’s orders, and clinical records were reviewed, and observations were made. The following was identified: Resident 2 had a physician’s order for the following: * Mechanical soft diet texture; * Set-up assistance at meals, and * Aspiration precaution instructions, which included: - Resident to sit fully upright; - Set-up meal tray; - Resident to have a slow rate of eating; and - Resident to stop eating if becomes fatigued and/or has increased coughing. Observations during the lunch service on 06/23/26 and 06/24/26 revealed Resident 2 received a regular texture diet and no set-up assistance. In an interview on 06/25/26 at 10:40 am, Staff 2 (RN/Health Services Director), and Staff 3 (LPN/Health Services Assistant) stated they would immediately update the dining services manager on Resident 2’s correct diet order for mechanical soft texture, and update staff with instructions for set-up assistance at all meals. The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (Interim ED), Staff 2 (RN/Health Services Director), and Staff 3 on 06/25/26 at 10:40 am. They acknowledged the findings. 2. Resident 6 was admitted into the facility in 10/2025 with diagnoses including dementia. The resident’s 06/01/26 through 06/22/26 MAR, current physician’s orders, and clinical records were reviewed, and observations were made. The following was identified: Resident 6 had a physician’s order for a “Mechanical Soft” diet. Observations from 06/22/26 and 06/23/26 revealed Resident 6 received a regular texture diet. The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Interim ED), Staff 2 (RN/Health Services Director), and Staff 3 (LPN/Health Services Assistant) on 06/25/26 at 11:20 am. They acknowledged the findings.

Residents 2 and 6's diet orders were immediately reviewed and verified with the physician orders. The nursing team completed an audit of all resident diet orders to verify physician-prescribed diets/meal assistance instructions. This is entered into PCC. Dietary Director to print the report from PCC and compile onto a sheet for the team, to easily see/read. These special orders are to be followed on every meal. To prevent recurrence, the nursing team, dietary, and direct care staff were educated on verifying and following physician diet orders. The nursing team will audit resident diet orders and meal service weekly for 90 days to ensure physician orders are carried out as prescribed. The Executive Director will track and ensure the corrections are made and monitored.

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 411-054-0090 (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 drills were conducted at least every other month and fire and life safety instruction was provided to staff on alternate months from the fire drills per the Oregon Fire Code (OFC). Findings include, but are not limited to: Six months of fire and life safety records from 12/2025 through 05/2026 were reviewed with Staff 4 (Maintenance Director) on 06/23/2026 at 11:12 am. The following was identified: * The facility lacked documented evidence unannounced fire drills were conducted and recorded every other month; and * The facility lacked documented evidence fire and life safety instruction was provided to staff on alternate months of the fire drills. The need to ensure fire drills were conducted and recorded at least every other month and fire and life safety instruction was provided to staff on alternate months from fire drills per the OFC was discussed at 9:55 am on 06/25/26 with Staff 1 (Interim ED). Staff 1 acknowledged the findings.

The facility completed a fire drill and provided fire and life safety education to staff. A fire drill and fire/life safety training schedule was established to ensure compliance. Maintenance Director was educated on Oregon Fire Code requirements for conducting fire drills every other month and providing fire and life safety instruction on alternate months. A tracking calendar was implemented for fire and life safety training topics, and fire drill and training records will be audited monthly for ongoing compliance by the Executive Director thru TELS platform and All Staff education topics.

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: