Print Inspection: RL013485

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 report physical injuries of unknown cause to the local Department office as suspected abuse unless an immediate facility investigation reasonably concluded and documented the physical injuries were not the result of abuse for 2 of 2 sampled residents (#s 1 and 3) who experienced injuries of unknown cause. Findings include, but are not limited to: 1. Resident 3 moved into the assisted living facility in 03/2023 with diagnoses including hypertension and a history of transient ischemic attacks. The resident’s clinical record, from 05/03/26 through 08/02/26, was reviewed, and the following was identified: a. Staff began alert charting in a progress note dated 05/11/26 for a “scratch” on Resident 3’s “left anterior elbow.” On 08/04/26 at approximately 3:30 pm, Staff 2 (Director of Nursing Services) verified there was no documented evidence that the facility’s investigation reasonably ruled out abuse or suspected abuse. b. On 06/13/26, staff began alert charting for a skin tear on Resident 3’s right wrist. There was no documented evidence that the facility’s investigation reasonably ruled out abuse or suspected abuse. On 08/04/26 at approximately 3:30 pm, Staff 1 (Director of Assisted Living Services) and Staff 2 confirmed the incidents had not been reported to the local Department office. The surveyor requested Staff 1 report the incidents to the local Department office. Confirmation of the reports was received on 08/05/26 at 9:04 am. 2. Resident 1 moved into the assisted living facility in 05/2026 with diagnoses including hyperlipidemia and supraventricular tachycardia. The resident’s clinical record, from 05/28/26 through 08/02/26, was reviewed, and the following was identified: a. Staff began alert charting in a progress note dated 07/01/26 for a “skin tear” on Resident 1s “right buttock.” On 08/04/26 at approximately 2:08 pm, Staff 1 (Assisted Living Services Director) and Staff 2 (Director of Nursing Services) verified there was no documented evidence that the facility’s investigation reasonably ruled out abuse or suspected abuse. b. On 07/07/26, staff began alert charting for a “bruise” on Resident 1s “right forearm.” There was no documented evidence that the facility’s investigation reasonably ruled out abuse or suspected abuse. On 08/04/26 at approximately 2:08 pm, Staff 1 and Staff 2 confirmed the incidents had not been reported to the local Department office. The surveyor requested Staff 1 report the incidents to the local Department office. Confirmation of the reports was received on 08/05/26 at 9:03 am.

1. Resident 1 and Resident 3 incidents were reported to APS on 8/4/2026. 2. All incident reports to be reviewed in the clinical meeting several times per week. Staff training will be completed on incident reporting & investigation and how to report to the department on nights and at weekends. All incident reports to be reviewed by the administrator to ensure completeness of invesitgations. 3. Incident reports to be reviewed several times per week in the clinical meeting. 4. Administrator and Director of Nursing Services.

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 ensure resident’s fall with injury was promptly investigated to rule out abuse or suspected abuse and reported to the local Department office if abuse could not reasonably be ruled out for 1 of 1 sampled resident (# 5) who experienced a fall with injury. This is a repeat citation. Findings include, but are not limited to: Resident 5 was admitted to the facility in 04/2026 with diagnoses including dementia. Staff 10 (Certified Nursing Assistant) reported in an interview on 10/15/26 at 1:00 pm, the resident required assistance of one staff with ADL care. The resident’s clinical record, from 10/05/26 through 10/15/26, was reviewed, and staff were interviewed. The following was identified: On 10/08/26, staff documented “. . . member was sitting on the floor between the bathroom door and [his/her] bed, [his/her] right outer forearm had noticeable dried blood to it, site was about 3-4 inches in length and 1cm in width and the depth was not measured but could see the yellow fatty tissue under the skin.” At the time of the incident the resident stated, “It’s nothing, just a scratch.” The LN (Licensed Nurse) determined it was a deep laceration and needed further treatment. Resident 5 was transported to the emergency room and returned with sutures to the right forearm. The fall was unwitnessed, and Resident 5 was unable to say how it happened. There was no documented evidence the facility immediately investigated the resident’s fall with injury to rule out abuse. On 10/15/26 at 1:35 pm, there was a dressing wrapped on the residents’ right forearm. When the surveyor attempted to interview Resident 5, s/he was not able to respond to questions appropriately. On 10/15/26 at 1:30 pm, Staff 4 (VP of Health and Wellness) confirmed an investigation of the resident’s fall with injury had not been completed. The need to ensure falls with injuries were immediately investigated to rule out abuse or reported to the local department office if abuse could not reasonably be ruled out was reviewed with Staff 4 on 10/15/26 at 4:00 pm. She acknowledged the findings.

1. Resident 5's incident was investigated on 10/15/2026. 2. All incident reports to be reviewed in the clinical meeting several times per week. Staff training will be completed on incident reporting & investigation and how to report to the department on nights and at weekends. All incident reports to be reviewed by the Administrator several times per week to ensure completeness of invesitgations. 3. Incident reports to be reviewed several times per week in the clinical meeting. 4. Administrator and Director of Nursing Services and Assistant Director of Nursing Services.

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 ensure resident’s fall with injury was promptly investigated to rule out abuse or suspected abuse and reported to the local Department office if abuse could not reasonably be ruled out for 1 of 1 sampled resident (# 5) who experienced a fall with injury. This is a repeat citation. Findings include, but are not limited to: Resident 5 was admitted to the facility in 04/2026 with diagnoses including dementia. Staff 10 (Certified Nursing Assistant) reported in an interview on 10/15/26 at 1:00 pm, the resident required assistance of one staff with ADL care. The resident’s clinical record, from 10/05/26 through 10/15/26, was reviewed, and staff were interviewed. The following was identified: On 10/08/26, staff documented “. . . member was sitting on the floor between the bathroom door and [his/her] bed, [his/her] right outer forearm had noticeable dried blood to it, site was about 3-4 inches in length and 1cm in width and the depth was not measured but could see the yellow fatty tissue under the skin.” At the time of the incident the resident stated, “It’s nothing, just a scratch.” The LN (Licensed Nurse) determined it was a deep laceration and needed further treatment. Resident 5 was transported to the emergency room and returned with sutures to the right forearm. The fall was unwitnessed, and Resident 5 was unable to say how it happened. There was no documented evidence the facility immediately investigated the resident’s fall with injury to rule out abuse. On 10/15/26 at 1:35 pm, there was a dressing wrapped on the residents’ right forearm. When the surveyor attempted to interview Resident 5, s/he was not able to respond to questions appropriately. On 10/15/26 at 1:30 pm, Staff 4 (VP of Health and Wellness) confirmed an investigation of the resident’s fall with injury had not been completed. The need to ensure falls with injuries were immediately investigated to rule out abuse or reported to the local department office if abuse could not reasonably be ruled out was reviewed with Staff 4 on 10/15/26 at 4:00 pm. She acknowledged the findings.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval Temporary rule language in effect until 02/05/2027 (2) The facility must not interfere with a good faith disclosure of information by an employee, volunteer concerning abuse or other action affecting a resident’s safety or welfare, as described in OAR 411-054-0028(4). (3) The Department must visit and inspect every licensed facility to determine whether the facility is maintained and operated in accordance with these rules. (a) The Department must inspect every facility at a minimum: (A) No less than 90 days and no more than 120 days after an initial license is issued or after a change of ownership of a facility. (B) Upon receipt of a license renewal application fee. (C) For each year during which a facility does not have a full survey, the Department must conduct an in-person inspection of the kitchen and other areas where food is prepared for residents. (b) Inspections may be conducted at other times as determined by the Department. (c) Facilities not in compliance with these rules must submit a plan of correction that satisfied the Department, within 10 business days of receipt of the inspection report. (d) Facilities must correct deficiencies within timeframes outlined in the accepted plan of correction. (e) Failure to be in substantial compliance upon reinspection may result in regulatory action to compel compliance. (f) Achieving substantial compliance is ultimately the facility’s responsibility, whether or not a plan of correction was followed. (g) The Department may impose sanctions for failure to comply with these rules. (4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to correct deficiencies within timeframes outlined in the accepted plan of correction. Findings include, but are not limited to: Refer to C231.

1. Resident #5's incident was reviewed by the Assistant Director of Nursing Services and the Director of Assisted Living Services. A retrospective investigation was completed to evaluate the circumstances surrounding the unwitnessed fall with injury and determine whether abuse could be reasonably ruled out. Findings were documented and maintained in the resident record. 2. To prevent recurrence, all nursing, caregiving, and leadership staff will be re-educated on abuse reporting requirements, injury of unknown cause determinations, and facility investigation procedures, including requirements for immediate investigation and reporting to APS when abuse cannot be reasonably ruled out. 3. The facility's incident investigation process and fall review tools have been revised to ensure unwitnessed falls with injury trigger immediate review for potential abuse, completion of a documented investigation, and required reporting. 4. Director of Nusring Services, Assistant Director of Nursing Services and the Director of Assisted Living Services will audit all incident reports involving resident injuries weekly for 90 days to verify investigations are completed, documented, and reported appropriately. Audit results will be reviewed through the facility Quality Assurance process and corrective action taken as needed.