Print Inspection: RL014715

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to immediately notify the local Department office or the local AAA (Area Agency on Aging) of any incident of abuse or suspected abuse and promptly investigate all reports of abuse for 1 of 2 sampled residents (#2) reviewed for incidents of suspected abuse. Findings include, but are not limited to: Resident 2 was admitted to the facility in 05/2025 with diagnoses including major depressive disorder. Resident 2’s clinical record, dated 07/12/26 through 10/05/26, was reviewed, and the following was identified: * On 07/23/26, a progress note indicated Resident 2 “showed antagonizing behaviors by chasing a w/c [sic] bound resident. This behavior upset and scared the other resident, as she/he was trying to get away from Resident 2, they continued to follow and chase him/her.” There was no documented evidence this incident was reported to the local Department office or AAA as an incident of suspected abuse. During an interview, on 10/07/26 at approximately 11:30am, Staff 1 (Administrator) confirmed the incident was not investigated and not reported to the local Department office or AAA. On 10/08/26 at 12:35pm, the need to ensure incidents of suspected abuse were immediately reported to the local Department office or AAA and investigated was discussed with Staff 1, Staff 2 (RN), Staff 3 (RCC), Staff 4 (Business Office Manager), and Staff 5 (Activities Director). They acknowledged the findings.

1. On 10/7/26, an incident report and investigation were completed and TSP was initiated for both residents. Appropriate notifications were made and reported to APS. A Medication Tech meeting was held with all Med Techs on 10/9 on identifying potential abuse and neglect, recognizing and reporting suspected abuse or neglect, documentation, notification and reporting procedures including verbal and posturing aggression. 2. Staff have been educated on when to notify the Administrator or designee of suspected abuse or neglect and when to complete an incident report. Administrative staff will review documentation per 24-hour reivew practices, and file reports based on the APS reporting guide. 3. Audits will be completed each week per Sapphire policy of the 24 hour system. Identified discrepancies in Incident reporting will be promptly corrected and education provided to person responsible. This audit will be completed for the next 4 weeks and brought to QA meetings for review. 4. The Administrator and RN

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to determine, document, and communicate to staff what actions or interventions were needed for a resident following a short-term change of condition and failed to note weekly progress of the condition until resolved for 1 of 2 sampled residents (#2) who experienced a change of condition. Findings include, but are not limited to: Resident 2 was admitted to the facility in 05/2025 with diagnoses including major depressive disorder. Review of Resident 2’s clinical record, dated 07/12/26 through 10/05/26, indicated the facility failed to determine, document, and communicate to staff what actions or resident-specific interventions were needed in response to the following short-term changes of condition: * On 07/23/26 -behaviors; and * On 08/07/26 - non-injury fall. On 10/08/26 at 12:35pm, the need to ensure the facility determined, documented, and communicated to staff what actions or interventions were needed in response to the resident experiencing short-term changes of condition was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RCC), Staff 4 (Business Office Manager), and Staff 5 (Activities Director). They acknowledged the findings.

1. The residents change of condition dated July 23rd for behaviors and August 7th for a non-injury fall were reviewed with resident-centered interventions on 10/7, prior to the completion of the licensing survey visit. RCC and RN were educated on ensuring resident specific intervetnions on TSPs for short term change of condition monitoring ongoing on 10/7. 2. Licensed nursing staff will asses changes of condition and develop, document, and implement person centered interventions on TSPs related to the short-term change in condition and review with staff weekly for revelency. 3. Short Term COC TSPs will be reviewed weekly with staff to ensure interventions remain person-centered. If intervention is deemed no longer person-centered, adjustments will be made, tracked and reassessed per Sapphire CQI system. Audits of system will be weekly for 4 weeks and monthly thereafter per Sapphire CQI. 4. The Administrator or designee will be responsible for monitoring short term COC documentation.

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/practitioner when a resident refused to consent to orders for 1 of 1 sampled resident (#1) who had documented medication refusals. Findings include, but are not limited to: Resident 2 was admitted to the facility in 05/2025 with diagnoses including major depressive disorder. The resident's 09/01/26 through 10/06/26 MARs and signed physician orders revealed the resident refused to consent to orders for the following medications: * Systane Ophthalmic Solution (dry eyes) on 63 occasions; * Fluticasone Proplonate 50 mcg/act Nasal Suspension (sinus infections) on 13 occasions; * Haloperidol Lactate 2mg/ml (agitation) once; and * NovoLIN 70/30 100 unit/ml (Type 1 Diabetes) once. On 10/08/26 at 12:35pm, the need to ensure the facility notified the physician or other practitioner if the resident refused consent to an order was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RCC), Staff 4 (Business Office Manager), and Staff 5 (Activities Director). They acknowledged the findings.

1. On 10/7/26, Hospice was notified of all resident specific medication refusals. Hospice reivewed with no recommendations. An audit was completed and med refusal notifications made to all providers. 2. On 10/9, all Medication Techs were educated on a resident rights to refuse medications, and the need to notify PCP per MD order. All MDs were faxed requesting frequency of desired notification for med refusals and monthly notifications were added to each resident MAR. More frequent notifications were also added to resident MAR per each PCP request. 3. The Administrator or designee will conduct weekly audits of medication refusals to ensure proper documentation, notification and any required follow up for the next 4 weeks. Audit will be conducted monthly thereafter per Sapphire CQI. 4. Administrator or designee will be responsible

OAR411-004-0020(2)(b) Physical Setting: Individual Accessible (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (b) The setting is physically accessible to an individual. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to have a setting that was physically accessible to an individual. Findings include, but are not limited to: Observations of the facility on 10/06/26 at approximately 10:45 am revealed the facility courtyard doors were locked and prevented residents from freely entering and exiting the facility. At approximately 11:00 am on 10/06/26, Staff 7 (MT) reported during an interview that residents could only access the courtyard with staff once the doors were unlocked and they were not allowed to go outside by themselves due to possible safety concerns. On 10/06/26 at approximately 1:45pm, the need to have the setting physically accessible to residents was discussed with Staff 1 (Administrator). She acknowledged the findings

1. All residents were immediately evalauated for the need for an IBL related to managing their own schedule and access to the courtyard. OPA for IBLs was consulted and administrative staff educated on appropriate use of IBLs. IBL's were updated to include access to courtyard for residents who were at risk or considered unsafe in the courtyard independently. IBLs were submitted to the case manager on 10/7. Additionally, code to courtyard remained posted for those who could access courtyard without assistance. 2. Immediate education on IBLs was sought out, imformation dispersed to team and IBLs updated. IBLs will be reviewed quarterly for COC and annually per OAR and HCBS requirements. 3. Area will be reviewed quarterly and annually per OAR and Sapphire CQI. 4. The Administrator or designee will be responsible

OAR411-004-0020(2)(i) Individual freedom & Support: Activities (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (i) Each individual has the freedom and support to control his or her own schedule and activities. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure individuals had the freedom and support to control his or her own schedule and activities for 1 of 1 sampled resident (#2) and five unsampled residents. Findings include, but are not limited to: During an acuity interview on 10/06/26 at approximately 9:30 am, it was reported the facility had six residents who vaped or smoked. Observations of the facility on 10/06/26 at approximately 10:45 am revealed the facility courtyard doors were locked and prevented residents from freely entering and exiting the facility. At approximately 11:00 am on 10/06/26, Staff 7 (MT) reported residents who smoked or vaped could only go outside to smoke or vape during designated smoke breaks. There were six identified smoke breaks in a 24-hour period. For the six residents who vaped or smoked, HCBS rights to freely control one’s own schedule and activities was being limited by the use of a smoking schedule. On 10/06/26 at approximately 1:45 am, the need to ensure residents were able to freely control their own schedule and activities was discussed with Staff 1 (Administrator). She acknowledged the findings.

1. All residents were immediately evalauated for the need for an IBL related to managing their own smoking schedule. Additionally, smoking habits, behaviors, and individual safety concerns were evaluated and considered during the development of their IBLs. OPA for IBLs was consulted and administrative staff educated on appropriate use of IBLs. IBL's were updated to include smoking for residents who smoke or vape and submitted to the case manager on 10/7. 2. Immediate education on IBLs was sought out, imformation dispersed to team and IBLs updated. IBLs will be reviewed quarterly for COC and annually per OAR and HCBS requirements. 3. Area will be reviewed quarterly and annually per OAR and Sapphire CQI. 4. The Administrator or designee will be responsible

OAR411-004-0040(1) Limitations: Threats To Health And Safety (1) When conditions under OAR 411-004-0020(2)(d) to (2)(j) may not be met due to threats to the health and safety of an individual or others, provider owned, controlled, or operated residential settings must apply individually-based limitations as described in this rule. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure Individually Based Limitations (IBLs) were completed when the need to restrict a residents’ rights arose. Findings include, but are not limited to: Refer to H1515 and H1522.

1. All residents were immediately evalauated for the need for an IBL (refer to H1515 and H1222) OPA for IBLs was consulted and administrative staff educated on appropriate use of IBLs. IBL's were updated and submitted to case manager on 10/7. 2. Immediate education on IBLs was sought out, information dispersed to team and IBLs updated. IBLs will be reviewed quarterly for COC and annually per OAR and HCBS requirements. 3. Area will be reviewed quarterly and annually per OAR and Sapphire CQI. 4. The Administrator or designee will be responsible