Marquis Oregon City Post Acute Rehab.

“There are no detail notes for this visit. There are no detail notes for this visit.”

“1. The facility's undated Friendship House Disclosure Statement revealed: -The physical design of Friendship House allows for wandering both inside and outside of the unit. There are several areas that are inviting to the residents and offer a place to sit and relax or have stimulating objects to investigate. An outside walkway is designed to allow for a safe wandering path. Exits from the entire hall are locked to prevent unsafe wandering. Residents living at Friendship House are free to wander about the common area and outside secured yard.-á On 2/25/26 at 9:30 AM a walkthrough of the secure memory care fenced courtyard and concurrent interview with Staff 1 (Administrator) revealed the following:-á -The walkway in the courtyard had moss growth and was slippery when walked on, this was acknowledged by Staff 1. -A box of fertilizer was observed in an open plastic box and was next to the table in the courtyard, Staff 1 stated the fertilizer was a hazard to the memory care residents. On 2/26/26 at 11:33 AM Staff 2 (DNS) provided a list which indicated 10 residents in the memory care unit were actively exit seeking.-á-á On 2/27/26 at 9:14 AM Staff 1 confirmed the memory care outside space presented safety risks to the residents in the memory care.-á 2. Resident 44 admitted to the facility in 5/2020 with diagnoses including dementia. Resident 44's comprehensive care plan revised 9/3/24 revealed Resident 44 required a sit to stand mechanical lift and two staff for all transfers. On 2/23/26 at 11:49 AM Staff 9 (CNA) was observed to transfer Resident 44 from her/his bed to a wheelchair without the assistance of as second staff member while using a sit to stand lift.-á On 2/25/26 at 11:19 AM Staff 9 stated Resident 44 required two staff for safe sit to stand transfers. Staff 9 stated she transferred Resident 44 independently on 2/23/26 and it was a lapse of judgement.-á On 2/26/26 at 11:26 AM Staff 2 (DNS) stated she was aware of the 2/23/26 transfer and stated Resident 44 required two staff for safe sit to stand transfers due to Resident 44 often moving during the sit to stand mechanical transfers. -á”

“The Centers for Medicare and Medicaid Services Center for Clinical Standards and Quality/Safety and Oversight Group letter 17-30, revised on 7/6/18, on Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease stated, ""Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water."" A review of the facility's revised 4/5/24 Water Management Program-Legionella revealed the following: -The facilityGÇÖs policy is to establish procedures to reduce the risk of Legionella and other opportunistic pathogens in the facilityGÇÖs water system. -A risk assessment is to be conducted by the water management team annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facilityGÇÖs water system. A review of the facilityGÇÖs Identifying Buildings at Increased Risk assessment indicated the assessment was completed on 3/27/24. On 2/26/26 at 11:05 AM Staff 1 (Administrator) and Staff 3 (Maintenance Director) acknowledged the annual risk analysis assessment for potential areas of growth and spread of water-borne pathogens, such as Legionella, in the facilityGÇÖs main water system was not completed since 3/27/24. The Centers for Medicare and Medicaid Services Center for Clinical Standards and Quality/Safety and Oversight Group letter 17-30, revised on 7/6/18, on Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease stated, ""Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water."" A review of the facility's revised 4/5/24 Water Management Program-Legionella revealed the following: -The facilityGÇÖs policy is to establish procedures to reduce the risk of Legionella and other opportunistic pathogens in the facilityGÇÖs water system. -A risk assessment is to be conducted by the water management team annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facilityGÇÖs water system. A review of the facilityGÇÖs Identifying Buildings at Increased Risk assessment indicated the assessment was completed on 3/27/24. On 2/26/26 at 11:05 AM Staff 1 (Administrator) and Staff 3 (Maintenance Director) acknowledged the annual risk analysis assessment for potential areas of growth and spread of water-borne pathogens, such as Legionella, in the facilityGÇÖs main water system was not completed since 3/27/24. On 2/26/2026 a risk assessment analysis and facility inspection for potential areas of growth and spread of water-borne pathogens was conducted by the Administrator and Maintenance Director and determined there are currently no potential areas for growth or contamination. These findings were shared with the Infection Preventionist. All current residents, staff, and visitors are potentially affected by the deficient practice. This facility utilizes TELS (Direct Supply’s The Equipment Lifecycle System) to track and document the timely completion of safety audits. TELS will now trigger an annual audit to be performed and completed by the Maintenance Director or designee, who will perform a new water-borne pathogen risk assessment and facility inspection, to be reviewed by the Maintenance Director, Administrator, and Infection Preventionist. Audits will be reviewed by the QAPI Committee, and follow up action assigned as needed. On 2/26/2026 a risk assessment analysis and facility inspection for potential areas of growth and spread of water-borne pathogens was conducted by the Administrator and Maintenance Director and determined there are currently no potential areas for growth or contamination. These findings were shared with the Infection Preventionist. All current residents, staff, and visitors are potentially affected by the deficient practice. This facility utilizes TELS (Direct Supply’s The Equipment Lifecycle System) to track and document the timely completion of safety audits. TELS will now trigger an annual audit to be performed and completed by the Maintenance Director or designee, who will perform a new water-borne pathogen risk assessment and facility inspection, to be reviewed by the Maintenance Director, Administrator, and Infection Preventionist. Audits will be reviewed by the QAPI Committee, and follow up action assigned as needed. There are no detail notes for this visit.”

“There are no detail notes for this visit. There are no detail notes for this visit.”

“There are no detail notes for this visit.”

“There are no detail notes for this visit. There are no detail notes for this visit.”

“The facility's Friendship House Disclosure Statement revealed: -The physical design of Friendship House allows for wandering both inside and outside of the unit. There are several areas that are inviting to the residents and offer a place to sit and relax or have stimulating objects to investigate. An outside walkway is designed to allow for a safe wandering path. Exits from the entire hall are locked to prevent unsafe wandering. Residents living at Friendship House are free to wander about the common area and outside secured yard.-á On 2/25/26 at 9:30 AM a walkthrough of the secure memory care fenced courtyard and concurrent interview with Staff 1 (Administrator) revealed the following:-á -A chair rested against the fence on the left-hand side of the outdoor space, a folding chair was against a tree near the back fence, and six lightweight and easily moved chairs were around a table. Staff 1 confirmed residents could use these chairs to exit the secure fenced area. -There was an approximately one foot by six-inch hole in the bottom of the back fences, the wood fence slats were jagged and sharp; Staff 1 acknowledged the hole in the fence.-á -á The facility's Friendship House Disclosure Statement revealed: -The physical design of Friendship House allows for wandering both inside and outside of the unit. There are several areas that are inviting to the residents and offer a place to sit and relax or have stimulating objects to investigate. An outside walkway is designed to allow for a safe wandering path. Exits from the entire hall are locked to prevent unsafe wandering. Residents living at Friendship House are free to wander about the common area and outside secured yard.-á On 2/25/26 at 9:30 AM a walkthrough of the secure memory care fenced courtyard and concurrent interview with Staff 1 (Administrator) revealed the following:-á -A chair rested against the fence on the left-hand side of the outdoor space, a folding chair was against a tree near the back fence, and six lightweight and easily moved chairs were around a table. Staff 1 confirmed residents could use these chairs to exit the secure fenced area. -There was an approximately one foot by six-inch hole in the bottom of the back fences, the wood fence slats were jagged and sharp; Staff 1 acknowledged the hole in the fence.-á -á On 2/25/2026, the lightweight furniture was removed permanently. On 2/26/2026, portions of the fence were replaced or repaired. Individuals who reside in the Friendship House and who may enter the courtyard area could be at risk if the fence is damaged, or if furniture and/or objects can easily be positioned near the fence as a means of improvised egress. This facility utilizes TELS (Direct Supply’s The Equipment Lifecycle System) to track and document the timely completion of safety audits. TELS will now trigger a quarterly audit to be performed and completed by the Maintenance Director or designee, who will inspect the Friendship House courtyard to identify the need for fence repair, the presence of any lightweight furniture or objects that could be used to exit the courtyard, and other potential hazards. Administrator or designee will perform a weekly observation of the Friendship House courtyard to identify any needed repairs or other potential hazards for 4 weeks, then monthly for 90 days. The results of these audits will be reviewed by the QAPI Committee, and any follow up action assigned as needed. On 2/25/2026, the lightweight furniture was removed permanently. On 2/26/2026, portions of the fence were replaced or repaired. Individuals who reside in the Friendship House and who may enter the courtyard area could be at risk if the fence is damaged, or if furniture and/or objects can easily be positioned near the fence as a means of improvised egress. This facility utilizes TELS (Direct Supply’s The Equipment Lifecycle System) to track and document the timely completion of safety audits. TELS will now trigger a quarterly audit to be performed and completed by the Maintenance Director or designee, who will inspect the Friendship House courtyard to identify the need for fence repair, the presence of any lightweight furniture or objects that could be used to exit the courtyard, and other potential hazards. Administrator or designee will perform a weekly observation of the Friendship House courtyard to identify any needed repairs or other potential hazards for 4 weeks, then monthly for 90 days. The results of these audits will be reviewed by the QAPI Committee, and any follow up action assigned as needed. There are no detail notes for this visit.”

“There are no detail notes for this visit. There are no detail notes for this visit.”

“Based on interview and record review it was determined the facility failed to obtain consents for the use of psychotropic medication for 2 of 7 sampled residents (#s 17 and 152) reviewed for medications. This placed residents at risk for the loss of the right to decline the use of psychotropic medications. Findings include: 1. Resident 17 was admitted to the facility in 9/2024 with diagnoses including fracture and heart failure. A 9/16/24 Admission MDS revealed Resident 17 was cognitively intact. Resident 17's 9/11/24 Physician Order indicated the resident was prescribed duloxetine (antidepressant) for pain. Resident 17's 9/2024 and 10/2024 MARs revealed the resident received duloxetine daily starting on 9/11/24. Review of Resident 17's health record revealed no documentation to indicate the resident was informed in advance of the risks and benefits of duloxetine. On 10/22/24 at 2:00 PM Staff 12 (RNCM) reviewed Resident 17's health record, acknowledged there was no documentation the resident was informed of the risks and benefits of duloxetine and confirmed a consent was not obtained prior to the resident starting the medication. 2. Resident 152 was admitted to the facility in 10/2024 with diagnoses including spinal stenosis and kidney disease. A 10/20/24 Admission MDS revealed Resident 152 was cognitively intact. Resident 152's 10/16/24 Physician Order indicated the resident was prescribed doxepin (antidepressant) for insomnia. Resident 152's 10/2024 MAR revealed the resident received doxepin starting on 10/17/24. Review of Resident 152's health record revealed no documentation to indicate the resident was informed in advance of the risks and benefits of doxepin. On 10/22/24 at 2:00 PM Staff 12 (RNCM) reviewed Resident 152's health record, acknowledged there was no documentation the resident was informed of the risks and benefits of doxepin and confirmed a consent was not obtained prior to the resident starting the medication. " Residents #152 and #17 were informed of the risks and benefits of the psychotropic medication that had been prescribed to them and signed consents were obtained for #152 on 10/21/2024 and #17 on 10/22/2024. " All residents receiving psychotropic medications are at risk of this deficient practice. The facility will conduct an audit on all residents receiving psychotropic medications to ensure that informed consents have been obtained and are in place. " The DNS will provide an in-service to the RCMs and Licensed Nurses no later than 12/13/2024 on the necessity of obtaining informed consent regarding the risks and benefits of psychotropic medications before treatment is initiated. " The DNS or designee will audit for the presence of informed consent(s) upon admission or upon a change in a residents psychotropic medications weekly for four weeks, and then monthly for three months to ensure ongoing compliance. " Any adverse findings will be addressed immediately, and the results of the audits will be presented at the next QAPI meeting for review and recommendation. " Date of Completion: December 13, 2024”

“Based on observation and interview the facility failed to ensure a clean, home-like environment for 1 of 1 memory care units and 1 of 1 dining halls observed. This placed residents at risk for lessened quality of life. Findings include: On 10/22/24 at 11:58 AM an observation during lunch service in the main dining room revealed the light fixtures had built up debris and dead insects inside eight of eight ceiling lights. On 10/24/24 at 10:45 AM an observation near the exit of the Memory Care Unit revealed debris and dead insects accumulated on two vent covers, and in one ceiling light fixture. On 10/24/24 at 11:19 AM and 11:57 AM Staff 14 (Maintenance Director) stated he usually cleaned vents annually and cleaned the light fixtures when he noticed they were dirty or someone told him they needed cleaning. Staff 14 stated the design of the lights was perfect for catching dust and insects "like a bowl." Staff 14 acknowledged the vents and light fixtures were not clean. • The identified light fixtures in the dining area and the vents in the Memory Care Unit were cleaned of debris on 10/22/2024 and 10/24/2024, respectively. • All residents residing in the facility are at risk of being affected by this deficient practice. • The Maintenance Director has made arrangements to clean the identified areas twice yearly and as needed moving forward. • The Maintenance director or Administrator will monitor for the presence of debris in the identified areas during routine facility-wide environmental rounds that occur throughout the year to prevent reoccurrence. Any negative findings will be addressed immediately by the Director of Maintenance or designee. • Date of Completion: December 13, 2024 There are no detail notes for this visit.”

“Based on interview and record review it was determined the facility failed to protect the resident's right to be free from physical and mental abuse by a resident for 1 of 1 resident (# 32) reviewed for abuse. This placed residents at risk for psychosocial harm. Findings include: Resident 38 was admitted to the facility in 6/2023 with diagnoses including dementia with behavioral disturbance. Resident 32 was admitted to the facility in 9/2024 with diagnoses including dementia with behavioral disturbance. A 9/20/24 Behavior/Psychotropic Meeting report included Resident 38 exhibited behavior problems including grabbing others on 9/11/24 and screaming at others on 9/23/24. A 9/25/24 Resident to Resident Event Assessment reported Staff 16 (CNA) heard two residents yelling in a room. Staff 16 entered the room and found Resident 38 straddling Resident 32 with her/his hands around Resident 32's neck. Staff 16 was required to intervene to remove Resident 38 off of Resident 32. The report indicated Resident 38 reported, "[Resident 32] was yelling and I told [her/him] I was going to kick [her/his] ass." The report indicated at that point Resident 38 got out of bed and put her/his hands around Resident 32's neck. On 10/23/24 at 10:05 AM Staff 16 (CNA) recalled the incident and stated he overheard yelling from Resident 32 and Resident 38's shared room. Staff 16 stated he was required to pull Resident 38 off Resident 32 and remove Resident 32 from the shared room. Staff 16 stated Resident 32 was distressed initially after the incident, but was able to calm down after an hour or two. On 10/23/24 at 10:14 AM Staff 17 (LPN) recalled Resident 32 stating she/he did not want to return to the room shared with Resident 38 after the incident. On 10/23/24 at 12:32 PM Staff 2 (DNS) confirmed the incident occurred and stated Resident 38's behavior towards Resident 32 was unacceptable. The identified deficient practice was determined to be past noncompliance as the facility put interventions in place to prevent additional incidents and in-serviced staff. The deficient practice was determined to be corrected on 10/10/24.”

“Based on interview and record review it was determined the facility failed to ensure the MDS was coded accurately related to the use of hearing devices for 1 of 2 sampled residents (#9) reviewed for hearing. This placed residents at risk for unassessed needs. Findings include: Resident 9 was admitted to the facility in 2019 with diagnoses including Parkinson's and anxiety. The 8/14/24 Annual MDS indicated the resident did not use hearing aids. The 8/14/24 Communication CAA revealed Resident 9 had a hard time hearing and often needed staff to raise their voice level when speaking to the resident. Staff were to speak in an elevated tone and face the resident when conversing. The CAA indicated Resident 9 did not use hearing aid devices but may eventually need hearing aids if her/his hearing worsened. On 10/23/24 at 3:05 PM and 10/24/24 at 11:52 AM Staff 3 (Social Services) stated the resident utilized hearing aids. Staff 3 stated she completed the 8/14/24 Annual MDS and Communication CAA, and acknowledged both were inaccurate. • A significant correction of resident #9’s prior CAA was completed to address the use of hearing devices. • All residents who use hearing devices are at risk of this deficient practice. • An audit was completed on the most recent annual MDS for residents who use hearing aids to ensure no other residents were impacted. Assessments were updated if indicated. • The SSD Consultant will in-service the SSD and LEC on comprehensive CAA assessments. • The SSD or designee will perform audits on CAA assessments related to Communication (hearing aid use) on comprehensive MDS weekly for four weeks and then monthly for three months to ensure on-going compliance. Any adverse findings will be addressed immediately, and the findings of the audits will be presented at the next QAPI meeting for review and recommendation. • Date of Completion: December 13, 2024 There are no detail notes for this visit.”

“Based on interview and record review it was determined the facility failed to comprehensively care plan cognitive impairment for 1 of 4 sampled residents (#47) reviewed for dementia. This placed residents at risk for unmet cognitive needs. Findings include: Resident 47 admitted to the facility in 8/2024 with diagnoses including diabetes. An 8/13/24 cognitive assessment revealed Resident 47 had severe cognitive deficits. A review of Resident 47's 8/27/24 care plan revealed no evidence of a cognitive deficit care plan. On 10/23/24 at 11:03 AM Staff 3 (SSD) acknowledged Resident 47 had severe cognitive deficits and was not care planned for cognitive deficits. • The comprehensive care plan was updated for resident #47 on 11/08/2024 to address cognitive impairment. • All residents who have been identified as being cognitively impaired are at risk of this deficient practice. • The SSD and LEC will conduct an audit of current residents identified as having cognitive impairment, care plans will be updated as indicated. • The SSD consultant will in-service the SSD and LEC for cognitive impairment comprehensive care plans to ensure cognitive impairment issues are adequately addressed by the care plan. • SSD consultant will conduct audits of the comprehensive care plans for those residents identified as having cognitive impairment to ensure said impairment is addressed in the care plan weekly for four weeks and then monthly for three months to ensure on-going compliance. Any adverse findings will be addressed immediately, and the findings of the audits will be presented at the next QAPI meeting for review and recommendation. • Date of Completion: December 13, 2024”

“Based on observation, interview and record review it was determined the facility failed to ensure staff assisted a resident with wearing hearing aids for 1 of 2 sampled residents (#35) reviewed for hearing. This placed residents at risk for a decline in communication. Findings include: Resident 35 was admitted to the facility in 7/2024 with diagnoses including dementia and anxiety. Review of Resident 35's Care Plan, revised on 8/16/24, revealed the resident had adequate hearing with hearing aids. Staff were instructed to place Resident 35's hearing aids in her/his ears in the morning, remove them at night, and place them on a charger on the night stand in a green container. Resident 35 might decline to wear her/his hearing aids due to them not being comfortable. A 9/11/24 Significant Change MDS revealed Resident 35 used hearing aids and her/his hearing was adequate. Resident 10 had a BIMS score of 10, indicating moderate cognitive impairment. A review of Resident 35's clinical record revealed no indication Resident 35 refused to have her/his hearing aids placed in her/his ears. On 10/21/24 at 11:24 AM Witness 2 (Family Member) stated when she visited Resident 35 during the day, the resident "never" had her/his hearing aids in. Witness 2 stated she placed them in the resident's ears and brought the concern up with staff but was not sure if anything was done to address the concern. On 10/22/24 at 11:00 AM Resident 35 stated she/he required assistance with putting her/his hearing aids in and staff did not always offer to assist with the hearing aids. Resident 35 stated she/he was hard of hearing without them. Random observations from 10/22/24 through 10/24/24 revealed Resident 35 had two hearing aids on her/his night stand in a green container being charged and not in Resident 35's ears. On 10/23/24 at 10:07 AM Resident 35 was heard asking staff to put in her/his hearing aids, however, no staff responded to her/his request, and multiple staff were in and out of the resident's room. On 10/23/24 at 10:44 AM Staff 5 (CNA), and at 1:01 PM Staff 6 (CNA), both stated Resident 35 was "very" hard of hearing and used hearing aids. Staff 5 acknowledged Resident 35 did not have her/his hearing aids in. Staff 5 and Staff 6 stated at times Resident 35 refused to wear the hearing aids, and they were supposed to document the refusals and report to the charge nurse. On 10/23/24 at 3:39 PM Staff 7 (CNA) stated Resident 35 was hard of hearing and required assistance with her/his hearing aids. Staff 7 stated the resident did not always have them in her/his ears when he came on shift. Staff 7 stated the hearing aids definitely helped with Resident 35's hearing. On 10/24/24 at 1:56 PM, Staff 4 (RNCM) stated Resident 35 required assistance with hearing aids being placed in her/his ears. Staff 4 stated Witness 2 reported concerns regarding the resident's hearing aids not being placed in her/his ears. Staff 4 stated she expected staff to offer to place Resident 35's hearing aids in the resident's ears. If Resident 35 refused, staff were to document in the clinical record and report the refusal to the charge nurse. Staff 4 acknowledged Resident 35's hearing aids were not being offered or placed in her/his ears. • On 11/12/24 Resident #35’s care plan was reviewed and updated with a new task added for staff to document assistance with applying the resident’s hearing aids. • All residents who require assistance with hearing aids have the potential to be affected by this deficient practice. • The facility completed an audit of all residents who require assistance with the placement of hearing aids to ensure their care plans reflect the need for assistance. • The DNS will in-service SSD and nursing staff on proper documentation of hearing aide use including refusal of use no later than 12/13/2024. • The SSD or designee will conduct audits of compliance with documentation for identified residents with hearing aids weekly for four weeks and then monthly for three months to ensure on-going compliance. Any adverse findings will be addressed immediately, and the findings of the audits will be presented at the next QAPI meeting for review and recommendation. • Date of Completion: December 13, 2024 There are no detail notes for this visit.”

“Based on observation, interview, and record review it was determined the facility had a medication error rate of greater than 5%. The facility's error rate was 18% with six errors in 33 opportunities. This placed residents at risk for inaccurate medication dosage and adverse consequences related to medications. Findings include: 1. Resident 14 admitted to the facility in 11/2019 with diagnoses including dementia. A review of Resident 14's physician orders revealed a 9/25/24 order for acidophilus pectin (probiotic) daily. On 10/23/24 at 9:24 AM Staff 13 (CMA) was observed administering medication to Resident 14. Staff 13 did not administer acidophilus pectin. A review of Resident 14's MAR revealed Staff 13 indicated she administered acidophilus pectin with the morning medications on 10/23/24. On 10/23/24 at 9:57 AM Staff 13 stated she did not administer acidophilus pectin. Staff 13 stated there was no acidophilus pectin in the medication cart and she was going to get a bottle from the medication storage room and administer it. On 10/23/24 at 10:04 AM Staff 4 (RNCM) stated medications were to be signed out when they were given and Staff 13 should have obtained the medication prior to signing it out. 2. Resident 19 admitted to the facility in 9/2024 with diagnoses including right knee pain. A review of Resident 19's physician orders revealed a 9/25/24 order for Lidocaine 5% patch: apply two patches, one to the posterior right knee and one to the anterior right knee. On 10/23/24 at 9:06 AM Staff 13 (CMA) was observed applying one lidocaine patch to Resident 19's right knee. On 10/23/24 at 9:58 AM Staff 13 stated she was unaware the orders stated to apply two lidocaine patches. On 10/23/24 at 10:10 AM Staff 12 (RNCM) stated she expected staff to read and follow the physician orders. Staff 12 stated two lidocaine patches should have been applied per physician orders. 3. Resident 45 admitted to the facility in 7/2024 with diagnoses including depression. a. A review of Resident 45's physician orders revealed an 10/22/24 order for acidophilus pectin (probiotic) daily. On 10/23/24 at 8:46 AM Staff 13 (CMA) was observed administering Resident 45's medications. Staff 13 did not administer acidophilus pectin. On 10/23/24 at 10:02 Staff 13 acknowledged she did not administer acidophilus pectin. Staff 13 stated there was no acidophilus/pectin in the medication cart and she was going to get a bottle from the medication storage room and administer the medication. On 10/23/24 at 10:12 AM Staff 12 (RNCM) stated medications were to be signed out when they were given and Staff 13 should have obtained the medication prior to signing it out. b. A review of Resident 45's physician orders revealed a 10/22/24 order for apripazole (a medication to treat depression) 7.5 mg daily. On 10/23/24 at 8:46 AM Staff 13 (CMA) was observed administering Resident 45's medications. Staff 13 administered apripazole 5 mg. On 10/23/24 at 10:02 Staff 13 acknowledged she did not administer the correct dose of apripazole. On 10/23/24 at 10:12 AM Staff 12 (RNCM) stated staff were expected to read and follow physician orders. c. A review of Resident 45's physician orders revealed a 10/22/24 order for budesonide formoterol fumarate inhaler: rinse with water and spit after each dose. On 10/23/24 at 8:46 AM Staff 13 (CMA) was observed administering Resident 45's budesonide formoterol fumarate inhaler without having Resident 45 rinse and spit after each dose. On 10/23/24 at 10:02 AM Staff 13 acknowledged she did not have Resident 45 rinse and spit after administering her/his inhaler. On 10/23/24 at 10:12 AM Staff 12 (RNCM) stated staff were expected to read and follow physician orders. 4. Resident 255 admitted to the facility in 10/2024 with diagnoses including chronic obstructive pulmonary disease. A review of Resident 255's physician orders revealed a 10/21/24 order for aclidinium bromide inhaler: rinse mouth after use. On 10/23/24 at 8:58 AM Staff 13 (CMA) was observed administering Resident 255's aclidinium bromide inhaler. Staff 13 did not have Resident 255 rinse her/his mouth after using the inhaler. On 10/23/24 at 10:00 AM Staff 13 stated she was unaware of the instructions to rinse the mouth after use of Resident 255's inhaler. On 10/23/24 at 10:10 AM Staff 12 (RNCM) stated staff were expected to read and follow physician's orders. • Residents #14, # 19, #255, and #45 suffered no adverse effects from staff member #13’s medication administration. • Staff member #13 was immediately re-inserviced on administration of medications per physician orders and 5 rights of medication administration. Staff member #13 will receive a competency evaluation before 12/13/2024. • All residents have the potential to be at risk of inaccurate medication administration which could lead to adverse effects. • DNS will in-service Licensed Nurses and CMAs on proper medication administration using the 5-rights of medication administration to prevent medication errors on no later than 12/13/2024. • The DNS or designee will conduct random medication pass audits at least weekly for four weeks and then monthly for three months to ensure ongoing compliance. Any adverse findings will be addressed immediately, and the findings of the audits will be presented at the next QAPI meeting for review and recommendation. • Date of Completion: December 13, 2024 There are no detail notes for this visit.”

“Based on observation and interview it was determined the facility failed to ensure medication storage was free of expired biologicals for 1 of 1 medication room reviewed for medication storage. This placed residents at risk for diminished treatment efficacy. Findings include: On 10/23/24 at 1:52 PM the medication storage refrigerator was observed to have three open vials of aplisol (tuberculosis test solution) with open dates in 7/2024. Each bottle indicated to discard 30 days after opening. On 10/23/24 at 1:56 PM Staff 2 (DNS) stated aplisol was to be discarded per the manufacturer's recommendation, 30 days after opening the vial. Staff 2 acknowledged all three vials of aplisol were open for greater than 30 days and needed to be discarded. • The biological agents that were found to be expired in the medication storage refrigerator were immediately disposed of. None of the expired biologicals had been used on residents after their expiration date. • All residents have the potential to be exposed to expired biological agents. • The DNS will in-service Licensed Nurses and CMAs on the routine cleaning of the med storage and disposal of expired biologicals by no later than 12/13/2024. • DNS or designee will conduct audits of med storage at least weekly for four weeks, then monthly for three months to ensure ongoing compliance. Any adverse findings will be addressed immediately, and the findings of the audits will be presented at the next QAPI meeting for review and recommendation. • Date of Completion: December 13, 2024 There are no detail notes for this visit.”

“There are no detail notes for this visit. There are no detail notes for this visit.”

“OAR-411-085-0310: Residents' Rights: Generally Refer to F552 ******************** OAR-411-087-0100: Physical Environment: Generally Refer to F584 ******************** OAR-411-085-0360: Abuse Refer to F600 ******************** OAR-411-086-0300: Clinical Records Refer to F641 ******************** OAR-411-086-0600: Comprehensive Assessments and Care Plan Refer to F656 ******************** OAR-411-086-0110: Nursing Services: Resident Care Refer to F676 and F759 ******************** OAR-411-086-0260: Pharmaceutical Services Refer to F761 ******************** There are no detail notes for this visit.”

“The findings of the state licensure and memory care unit health survey conducted from 10/21/24 through 10/24/24 are documented in this report. It was determined the facility was in compliance with OAR 411 Division 57. A follow-up survey was conducted on 12/19/24 to verify correction of the deficiencies noted from the memory care community health survey dated 10/24/24. These deficiencies are corrected as of 12/13/24.”

“There are no detail notes for this visit. There are no detail notes for this visit.”

“Based on interview and record review it was determined the facility failed to ensure residents were free from abuse for 1 of 4 sampled residents (#7) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 7 admitted to the facility in 3/2020, with diagnoses including unspecified dementia and acute kidney failure. Resident 7's Quarterly MDS dated 6/18/24 revealed a BIMS score of 4, which indicated severe cognitive impairment. Resident 8 admitted to the facility in 8/2022 with diagnoses including Alzheimer's Disease and diabetes. Resident 8's Progress Note revealed on 9/14/22, she/he was observed trying to touch other residents in the groin area. When confronted by staff, Resident 8 "would stop what she/he was doing and move onto the next closest female/male and start to grab their hands and then slowly rub their leg and try to creep her/his hand slowly to their groin area. Patient was redirected several times." Resident 8's Quarterly MDS dated 3/12/24 revealed a BIMS score of 9, which indicated moderate cognitive impairment. Resident 8's most recent care plan, revised on 7/10/23 revealed the resident had both verbal and physical inappropriate sexual behaviors, which included a history of inappropriately touching residents of the opposite gender since 2022. Resident 8's care plan interventions included one to one supervision as needed, supervision during group activities and meal times, staff to seat resident next to the same gender in group activities and line of sight supervision if one to one supervision could not be provided. On 3/13/23 the State Survey Agency (SSA) received a Facility Reported Incident (FRI), which revealed on 3/13/23 at 3:25 PM, Resident 8 was observed by staff with her/his hand down the front of Resident 7's pants. The residents were in the dining room watching a movie and Staff 9 (Former Activities Director) left the dining room briefly. When Staff 9 returned to the dining room, she observed the incident. The residents were separated and assessed by Staff 9. The report indicated Resident 7 did not experience psychosocial distress as a result of the incident. A Progress Note dated 3/13/23 at 11:40 PM, revealed after the incident Resident 8 was placed on 15 minute checks. Resident 8 was not interviewed due to discharging from the facility. On 7/24/24 at 9:59 AM, Resident 7 was observed to be lying in bed. She/he had no recall of the incident. On 7/24/24 at 10:15 AM, Staff 10 (CNA) recalled both residents and noted Resident 8 "was just a little too friendly" with residents of the opposite gender and was to be closely supervised while out of her/his room. On 7/26/24 at 1:55 PM, Staff 7 (Life Enrichment Coordinator) recalled the incident and stated staff were instructed to keep an eye on Resident 8, not leave her/him with other female/male residents due to her/his behaviors which included her/him rubbing or touching other resident's bodies without their consent. On 7/29/23 at 11:38 AM, Staff 5 (RCM) stated Resident 8 was placed on one to one supervision in 7/2023 due to another incident involving a different resident. She stated the 3/2023 incident with Resident 7 resulted in Resident 8 being placed on 15 minute checks and not seated by residents of the opposite gender. On 7/29/24 at 1:00 PM, Staff 1 (Administrator) and Staff 2 (DNS) were notified of the investigative findings. • Resident 8 is no longer at the facility. • Following the July incident on 7/10/23 the facility assigned a staff member to specifically supervise resident 8 one-to-one from 7am to 7pm daily, and later than 7pm as needed until resident 8 went to bed. One-to-one supervision was staffed until resident 8 discharged on 4/10/2024. Resident 7 did not experience psychosocial distress as the result of the incident and had no recall of the incident when interviewed by staff after the 7/10/23 incident. • All female residents had the potential to be affected by this deficient practice. • The facility’s Administrator will provide an in-service to the staff during the next all-staff meeting on 8/9/24 on abuse identification and prevention. The facility also provides on-going education to staff to help them recognize the signs and symptoms of potential abuse. • Facility Administrator and/or SSD will conduct random resident interviews weekly x 4 weeks and then monthly x 90 days – inquiring of residents if any unwanted touching has occurred with another resident. Any response to the positive will immediately be reported and investigated. All reports will be reviewed in facility QA Committee. • Facility DNS, or designee, will randomly observe dinning areas/activities or other areas of close resident gathering for auditing weekly X 4 weeks and monthly X 90 days. Reports of audits to be reviewed at facility QA committee. • Compliance Date: 8/10/2024 There are no detail notes for this visit.”

“There are no detail notes for this visit. There are no detail notes for this visit.”

“************************************************** OAR 411-085-0360 - Abuse Refer to F600 ************************************************** There are no detail notes for this visit.”