Curry Manor.

“Based on interview and record review, conducted during a site visit on 01/16/25, the facility's failure to have a fully implemented and updated Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to: A review of the facility's ABST indicated that not all resident specific data had been updated at least quarterly. Some residents had not been updated in over a year. In an interview on 01/16/25, Staff 1 (Executive Director) stated the following: · They usually updated the tool when the service plan was reviewed. · They were currently working on updating the service plans and tool since their recent survey. The facility failed to update and document the ABST evaluation for each resident no less than quarterly and corresponding with resident service plan updates. Findings were reviewed with and acknowledged by Staff 1. Based on interview and record review, conducted during a site visit on 01/16/25, the facility's failure to have a fully implemented and updated Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to: A review of the facility's ABST indicated that not all resident specific data had been updated at least quarterly. Some residents had not been updated in over a year. In an interview on 01/16/25, Staff 1 (Executive Director) stated the following: · They usually updated the tool when the service plan was reviewed. · They were currently working on updating the service plans and tool since their recent survey. The facility failed to update and document the ABST evaluation for each resident no less than quarterly and corresponding with resident service plan updates. Findings were reviewed with and acknowledged by Staff 1.”

“Based on observation, interview, and record review, it was determined the facility failed to ensure delegation and teaching was provided and documented by a RN in accordance with the Oregon Administrative Rules (OAR) adopted by the Oregon State Board of Nursing (OSBN) in chapter 851, division 047 for 1 of 1 sampled resident (#1) who received insulin injections by a facility unregulated assistive person (UAP). Findings include, but are not limited to: Pursuant to OAR chapter 851 division 006, delegation process means the process utilized by an RN to authorize an UAP to perform a nursing procedure for a client, the outcome of which the RN retains accountability for. The RN must document all delegation process decisions, actions and outcomes pursuant OAR 851-045 including comprehensive assessment, reasoned conclusions that identify client problems and risks, educate the UAP and evaluate their learned knowledge, and provide a one-on-one education and evaluation experience with the UAP and the client. During the acuity interview on 11/18/24, Resident 1 was identified to be administered an insulin injection four times daily by a facility UAP. Resident 1's MARs from 10/01/24 through 11/18/24 revealed insulin injections had been given by Staff 10 (RCC), Staff 23 (MT), and two other UAPs who were no longer employed at the facility. On 11/20/24, the surveyor observed Staff 23 prepare and administer an insulin injection to Resident 1. Staff 2 (RN) assumed nursing oversight at the facility on 10/01/24. During the interview on 11/19/24 at 4:40 pm, Staff 2 stated the previous RN had terminated employment without transferring nursing delegation. The previous nursing delegation binders contained multiple forms without clear and appropriate delegation documentation. Upon starting employment, Staff 2 created a new nursing delegation binder, including comprehensive RN assessments for all residents who received insulin injections by facility UAP. During the interviews on 11/20/24 and 11/21/24, Staff 2 confirmed Staff 10 and Staff 23 were not delegated to prepare and administer insulin injections for Resident 1. Training and initial delegation for Staff 10 and Staff 23 were completed while the survey team was on site. Staff 2 verbalized understanding that the facility RN bore ultimate responsibility for all nursing tasks administered by UAPs in the facility. The need to ensure nursing delegation and teaching to facility UAPs was provided and documented by a RN in accordance with the Oregon Administrative Rules (OAR) adopted by the Oregon State Board of Nursing (OSBN) in chapter 851, division 047 was reviewed with Staff 1 (ED) and Staff 2 on 11/21/24 at 3:00 pm. They acknowledged the findings. All delegations for Med-tech's have been completed. The new hire for Med-tech will shadow a trained Med-tech for 2 days, then observed passing medications by the trainer. The RN will do medication pass observation and if RN determines he/she is competent the Med-tech will work for at least 1 week to become elegible for delegated. As persons are hired the business office manager and the RCC will review training and report to the RN when the new hire has completed the training. ED or designee. OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching (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:(B) Delegation and Teaching. Delegation and teaching must be provided and documented by a RN in accordance with the Oregon Administrative Rules adopted by the Oregon State Board of Nursing in chapter 851, division 047. This Rule is not met as evidenced by:”

“Based on observation, interview, and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, resident outcomes, and resident satisfaction. Findings include, but are not limited to: During the survey, conducted 07/21/25 through 07/25/25, quality improvement oversight to ensure adequate resident care, services, and satisfaction was found to be ineffective. In an interview at 9:25 am on 07/25/25, Staff 1 (Executive Director) stated there was no documentation of the facility conducting a specific ongoing quality improvement program. The need to ensure the facility developed and conducted ongoing quality improvement programs was reviewed with Staff 1, Staff 2 (Assistant Executive Director), and Staff 3 (RN) on 07/25/25 at 9:30 am. They acknowledged the findings.”

“Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents, related to residents who required a secured memory care environment. Findings include, but are not limited to: The facility was an endorsed memory care community (MCC), which is defined as “a special care unit in a designated, separated area for residents with Alzheimer's disease or other forms of dementia that is locked or secured to prevent or limit access by a resident outside the designated or separated area.” During the acuity interview on 07/21/25, Staff 1 (Executive Director), Staff 3 (RN), and Staff 26 (RCC) identified 36 residents as residing in the MCC. Of the 36 residents, four were identified as having a history or risk of elopement and/or wandering the facility exit seeking. Throughout the survey, dated 07/21/25 through 07/25/25, the survey team observed Resident 8 approaching and attempting to open locked doors and windows throughout the MCC as s/he sought exit. a. The survey team identified two resident rooms which had sliding patio doors which opened easily and led to an unsecured outdoor area which included a hill, water feature, and accessed a large field. Both resident rooms were occupied. The doors did not have an alarm or other system to notify staff if a resident exited the facility into the unsecured area. During an interview at 8:30 am on 07/22/25, Staff 18 (MT) stated she was aware of the door in room 20 and had observed one of the room’s residents outside in the unsecured area “at times.” She stated that the unsecured courtyard was not considered a resident area. She stated other doors leading from resident areas, such as the dining room and living room, had keypad codes preventing residents from exiting into the unsecured courtyard without staff assistance. Staff 2 (Assistant Executive Director) stated at 8:35 am on 07/22/25 that she was aware that rooms 20 and 22 had patio doors which exited into an unsecured area. She confirmed that the outdoor area was not considered part of the secured MCC. She stated that she would address the safety concern “right now” with Staff 25 (Maintenance Director). At 3:50 pm on 07/22/25, the survey team identified that the patio doors continued to open, unimpeded, to the unsecured outdoor area. At 4:00 pm on 07/22/25, Staff 2 confirmed that no measures had been taken to prevent resident access to the unsecured area, but that she would address it immediately. At 4:19 pm on 07/22/25, the survey team confirmed that the patio doors had a physical limiter installed which prevented residents from accessing the unsecured area. b. On 07/24/25, the survey team identified windows in nine MCC resident rooms which opened fully and were at a height which could reasonably allow residents to access outdoor areas which were unsecured, including a parking lot, hill and field. Two windows in the MCC dining area opened fully and allowed for access to an unsecured outdoor area. In an interview on 07/24/25 at 3:30 pm, Staff 1 confirmed that the windows did not have a system to ensure residents in the MCC remained in the secured environment. She stated the facility had to remove limiters on the windows in the past, prior to her working at the facility, due to instruction from the local Fire Marshal’s office. She stated the facility had no documentation of this instruction. During interviews between 4:00 pm and 4:03 pm on 07/24/25, multiple facility staff stated that an unsampled resident who currently resided in the MCC who had previously exited the facility by climbing out his/her window, and the staff expected that s/he would attempt this again in the future. The facility staff identified 5 other residents who had a history or risk of elopement. On 07/24/25 at 5:39 pm, after discussions via phone with the CBC survey team and CBC management, the facility’s Oregon Policy Analyst, and Witness 1 (Division Chief - Fire Marshal, Central Douglas Fire & Rescue), the facility instituted a policy of documenting that each resident was visibly identified every 30 minutes to ensure all residents were accounted for inside the secured MCC. The need to ensure reasonable precautions were exercised against any condition that could threaten the health, safety or welfare of residents was reviewed with Staff 1, Staff 2 and Staff 3 (RN) on 07/25/25 at 9:30 am. They acknowledged the findings.”

“Based on interview and record review, it was determined the facility failed to ensure incidents of abuse or suspected abuse were immediately investigated to rule out abuse or neglect and/or reported to the local SPD office and to ensure injuries of unknown cause were reported to the local SPD unless an immediate facility investigation reasonably determined the injury was not the result of abuse for 3 of 5 sampled residents (#s 3, 4, and 5) whose records were reviewed. Findings include, but are not limited to:”

“Based on observation, interview, and record review, it was determined the facility failed to provide an activity program based on individual and group interests, physical, mental, and psychosocial needs, and opportunities for active participation in the community at large. Findings include, but are not limited to: Observations conducted on 01/21/26 and 01/22/26 revealed a January activities calendar was posted in the MCC; however, no activities calendar was posted in the RCF. Review of the MCC activities calendar showed the following: Trivia was scheduled daily at 11:30 am; and Bingo was scheduled daily at 3:00 pm. On nine of the 31 days in January, there were only two activities listed: Trivia at 11:30 am and Bingo at 3:00 pm. On the remaining days, a third activity was listed, which consisted of one of the following: cooking club, book club, bible study, mail call, or movie and popcorn. No activities were scheduled or listed after 3:00 pm on any day. In interviews completed on 01/21/26 and 01/22/26, unsampled residents in the RCF confirmed there was no activities calendar available or posted. When asked what activities were offered that day, one resident pointed to a single piece of paper taped to the wall that stated, “Bingo at 3:00 pm.” When asked if any additional activities were offered, the resident stated “no” and reported spending the day sitting and waiting. Interviews completed on 01/21/26 and 01/22/26 with unsampled residents in the MCC revealed the residents spent the majority of the day sitting, watching television, or waiting for scheduled smoke breaks. One resident stated the scheduled activities, including bingo, did not align with his/her interests and described the activities as juvenile. Two residents stated they wanted to move to another facility in town due to the availability of more activities and outings and reported there was “nothing to do” at the current facility. In an interview on 01/21/26 at approximately 2:50, Staff 34 (Activities Director/Receptionist) stated activity evaluations had not been completed for most residents and acknowledged the overall activities program needed improvement. She stated there were designated activity staff scheduled Wednesday through Sunday but said care staff were responsible for orchestrating activities on the other two days. On 01/22/26 at 1:00 pm, the need to ensure an activities program based on individual and group interests, and which was person-centered and available during residents’ waking hours, was discussed with Staff 1 (Executive Director) and Staff 2 (Assistant Executive Director). They acknowledged the findings.”

“Based on interview and record review, it was determined the facility failed to ensure the move-in evaluation contained all required elements and addressed sufficient information to develop an initial service plan to meet the resident’s needs for 1 of 1 sampled resident (#6) who was recently admitted to the facility. Findings include, but are not limited to: Resident 6 moved into the facility in 09/2024 with diagnoses including dementia. The initial evaluation was reviewed and failed to address the following required elements: * Physical health status including list of current diagnoses, list of medications and PRN use, visits to health practitioner(s), emergency room, hospital or nursing facility in the past year and vital signs if indicated by diagnosis, health problems or medications; * Cognition, including memory, orientation, confusion and decision-making abilities; * List of treatments, type, frequency and level of assistance needed; * Indicators of nursing needs including potential for delegated nursing tasks; * Emergency evaluation ability; * Complex medication regimen; * Fall Risk or history; * Emergency evacuation ability; * Complex medication regimen; * History of dehydration or unexplained weight loss or gain; * Recent losses; * Unsuccessful prior placements; * Elopement risk or history; * Smoking, ability to smoke safely; * Alcohol and drug use; and * Environmental factors that impact the resident’s behavior including, but not limited to: noise, lighting and room temperature. Staff 7 (Marketing Director) on 11/21/24 at 8:40 am acknowledged the information was incomplete and stated there was difficulty obtaining information from Resident 6 at the time of the evaluation. The need to ensure the move-in evaluation included all required elements was discussed with Staff 7 on 11/21/24 at 8:40 am, and Staff 1 (ED) and Staff 2 (Assistant ED) on 11/21/24 at 2:30 pm. The findings were acknowledged. Resident evaluation has been updated to reflect required information related to the new-move in. Marketing Director and RCC will ensure the resident evaluation has been completed prior to move in. Assistant ED and ED will review the new admission for the needed evaluations prior to move in. The ED or designee OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and ass”

“Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear direction to staff regarding the delivery of services for 4 of 5 sampled residents (#s 1, 2, 3, and 5) whose service plans were reviewed. Findings include, but are not limited to:”

“Based on observation, interview, and record review, it was determined the facility failed to evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed for a significant change of condition, and failed to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff, document progress until the condition resolved for 3 of 5 sampled residents (#s 1, 2, and 3) who experienced changes of condition. Findings include, but are not limited to:”

“Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessed a significant change of condition for 1 of 1 sampled resident (#9) who experienced significant weight loss. Findings include, but are not limited to: Resident 9 was admitted to the facility in 11/2022 with diagnoses including vascular dementia. During the acuity interview on 07/21/25, Resident 9 was identified as being on hospice. The resident’s 06/18/25 service plan, 04/23/25 through 07/18/25 progress notes, 05/01/25 through 07/01/25 temporary service plans (TSPs), and 01/01/25 through 07/15/25 weight records were reviewed. Observations were made, and staff were interviewed. Weight records indicated the following: * 03/01/25: 107.2 pounds; * 04/01/25: 75 pounds; * 05/01/25: 107.8 pounds; * 06/01/25: 107.8 pounds: * 07/01/25: 101.8 pounds; and * 07/15/25: 102.2 pounds. A quarterly nursing assessment completed on 04/03/25 indicated the 75 pound weight on 04/01/25 was incorrect and was actually 110 pounds. Between 06/01/25 and 07/01/25 the resident lost 6 pounds, or 5.56% of his/her total body weight. This constituted a significant change of condition, for which an RN assessment should have been completed. Observations of Resident 9 during the lunch meal on 07/22/25 and 07/23/25 showed staff sat with the resident and attempted to feed him/her when s/he did not feed himself/herself. The resident was resistant to being fed during both meals. On 07/22/25, the resident ate less than 25% of his/her lunch. On 07/23/25, s/he ate 50% of his/her lunch. A TSP dated 07/01/25 instructed staff to “Help and monitor [Resident 9] at all meal times [sic] [with] ensures [sic] to help [with his/her] weight loss.” Alert charting for this TSP was resolved on 07/18/25, with a progress note that stated, “Not eating all [his/her] food. Has a meal companion to help [him/her] eat better.” There was no documented evidence a significant change of condition assessment had been completed by the RN. On 07/23/25 at 10:01 am, when asked for a copy of the significant change of condition assessment for Resident 9’s weight loss, Staff 3 (RN) replied, “[Resident 9 is] on hospice. I don’t do significant changes [of condition assessments] for hospice. They do their own.” In an interview on 07/24/25 at 9:55 am, Staff 1 (Executive Director) confirmed the RN did not do significant change assessments for residents on hospice. The need for all significant changes of condition, including for residents on hospice, to be assessed by an RN was discussed with Staff 1 and Staff 2 (Assistant Executive Director) on 07/24/25 at 9:55 am. They acknowledged the findings.”

“Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled resident (#1) whose MARs and controlled substance disposition logs were reviewed for accuracy. Findings include, but are not limited to: Resident 1 was admitted to the facility in 11/2022 with diagnoses including type 2 diabetes mellitus and chronic kidney disease. Resident 1's MAR from 10/01/24 through 11/18/24, the facility’s controlled substance disposition logs, and the resident’s current physician orders were reviewed. Resident 1 had a physician order for oxycodone/acetaminophen [APAP] 5-325 mg, one tablet orally every six hours as needed for chronic pain. The following inaccuracies were identified between the resident's MAR and the controlled substance disposition log: a. The controlled substance disposition log recorded dispensing the following doses: * 10/12/24 at 1:20 am; * 10/13/24 at 7:00 pm; * 11/02/24 at 6:00 pm; and * 11/17/24 at 8:00 pm. There was no record the above doses had been administered in the resident’s MAR. b. According to the resident’s MAR, a dose was documented as administered on 10/08/24 at 9:21 am, but the controlled substance disposition log did not have a record of this administration. In an interview on 11/19/24 at 3:20 pm Staff 3 (RN) acknowledged the discrepancies. The need to ensure the facility had an effective system for tracking controlled substances was reviewed with Staff 1 (ED) and Staff 2 (Assistant ED) on 11/21/24 at 3:00 pm. They acknowledged the findings. We are unable to go back and correct the past but in the future the medications signed out will also be signed in the MAR. The RCC will review the narcotic books and match the signed out narcotics to the MAR daily during the week. The LPN will review the books monthly. The Med-tech will be notified to come in the same day to remedy the problem. Managed Health Care Pharmacy comes in quarterly to audit the narcotic books, MARs and the system. RN or designee will audit for discrepancies weekly. OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by:”

“Based on interview and record review, it was determined the facility failed to ensure physician's orders were carried out as prescribed for 2 of 5 sampled residents (#s 1 and 5) whose orders were reviewed. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to ensure the physician or other legally recognized practitioner was notified when a resident refused to consent to an order for 3 of 3 sampled residents (#s 1, 3, and 5) who had medication refusals. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept for all facility administered medications and the MAR included resident-specific parameters and instructions for PRN medications for 2 of 3 sampled residents (#s 7 and 8) whose MARs were reviewed. Findings include, but are not limited to:”

“Based on observation, interview, and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications were evaluated upon move-in and at least quarterly thereafter to assure the residents’ ability to safely self-administer medications and had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications for 1 of 1 sampled resident (# 2) who was reviewed for self-administration. Findings include, but are not limited to: Resident 2 was admitted to the facility in 11/2022 with diagnoses including hypertension, depression, and chronic obstructive pulmonary disease (COPD). During the acuity interview on 11/18/24, Resident 2 was identified as self-administering all of his/her medications. This was confirmed by Staff 23 (MT) in an interview on 11/20/24 who stated “s/he started [self-administering] sometime last week.” During the interview with Resident 2 on 11/20/24, s/he stated a family member came every afternoon and prepared the medications for the upcoming day by using a daily pill box. Resident 2 confirmed the self-administration arrangement had been in place “for about a week or something like that.” Neither the resident nor the family member had a list of currently prescribed medications. Resident 2 stated “my [family member] follows the directions written on the bottles or medication cards.” Two of the medications treated blood pressure, and the related physician orders included blood pressure parameters about which Resident 2 was unclear. Additionally, Resident 2 had a scheduled order for a controlled substance medication to treat chronic pain. Review of Resident 2’s medical records revealed there was no documented evaluation of Resident 2's ability to safely self-administer medications, and no physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications was given. In an interview on 11/20/24 at 12:20 pm, Staff 1 (ED) and Staff 3 (RN) confirmed no physician or other legally recognized practitioner’s written order or self-administration evaluation were available. On 11/21/24, Staff 3 notified the survey team the self-administration assessment of Resident 2 had been completed on 11/20/24, and the resident was unable to safely prepare and administer prescribed medications. Resident 2’s family member transferred all medications and the responsibility of administration to the facility on 11/21/24. The transfer of responsibility was confirmed by Resident 2 on 11/21/24 at 12:16 pm. The need to ensure residents who chose to self-administer their medications were evaluated upon move-in and at least quarterly thereafter to assure the residents’ ability to safely self-administer medications and had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications was reviewed with Staff 1 and Staff 2 (Assistant ED) on 11/21/24 at 3:00 pm. They acknowledged the findings. For Resident 1, the-self administration of medication was rescinded due to evaluation indicated he was not appropriate for self-administration. All residents wanting to self administer will have an assessment by the RN for self-administering of their medications. If appropriate the RN/LPN will obtain an order for self-administering. The resident will be taught to initial the MAR and follow all needed instructions for this medication. The RCC will be audited weekly for descrepancies and corrections. The RN/LPN or designee will review the audits monthly or sooner if descrepancies are found. OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order. This Rule is not met as evidenced by:”

“Based on observation, interview, and record review, it was determined the facility failed to ensure they accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan for 4 of 5 sampled residents (#s 1, 2, 3, and 5) whose acuity-based staffing tool (ABST) were reviewed. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) evaluation for each resident was updated with significant changes of condition and/or quarterly at the same time the resident’s service plan was updated for 2 of 5 (#s 2 and 5) sampled residents whose ABST data was reviewed. Findings include, but are not limited to: The facility’s ABST data and posted staffing plan were reviewed on 11/19/24 at 1:25 pm. The following was identified: Review of the ABST data for Residents 2 and 5 revealed there was no documented evidence the ABST had been reviewed and updated quarterly and/or with significant changes of condition. Therefore, the ABST did not generate an accurate staffing plan. The need to ensure the ABST evaluation for each resident was updated with significant changes of condition and/or quarterly at the same time the resident’s service plan was updated was discussed with Staff 1 (ED) and Staff 2 (Assistant ED) on 11/21/24 at 2:30 pm. They acknowledged the findings. Resident's 1, 2, 3, and 5's ABST was reviewed and corrected to reflect resident needs. The ABST questionaire provided by the state will be handed out to the care-partners quarterly as service plans are updated and with change of conditions. The ABST will be reviewed with the Annual, Quarterly, New Admissions and Change of Condition Service plans. The ED will update the posted staffing plans if there are changes weekly. The Assistant ED or designee will audit the ABST questionaire weekly for 3 weeks then monthly for 3 months. OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) evaluation was updated and reviewed no less than quarterly at the same time the service plan was updated for 2 of 2 sampled residents (#s 8 and 9) who had a quarterly service plan completed and ten unsampled residents whose ABST evaluation dates were reviewed. This is a repeat citation. Findings include, but are not limited to: The facility’s ABST was reviewed on 07/21/25. The following was identified: Twelve of the residents, including Resident 8, Resident 9, and ten unsampled residents, did not have evidence that ABST evaluation updates were completed at least quarterly at the same time as service plan updates. The need to ensure residents’ ABST evaluations were updated no less than quarterly was reviewed with Staff 1 (Executive Director), Staff 2 (Assistant Executive Director), and Staff 3 (RN) on 07/25/25 at 9:30 am. They acknowledged the findings.”

“Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly hired direct care staff (#s 15, 17, and 21) completed abdominal thrust training within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed with Staff 8 (Business Office Manager) on 11/21/24. Staff 8 reported abdominal thrust training had not been completed for Staff 15 (CG), hired 10/15/24, Staff 17 (CG), hired 10/15/24, and Staff 21 (MT), hired 08/12/24. The need to ensure all training was completed within the required timeframe was discussed with Staff 1 (ED) and Staff 2 (Assistant ED) on 11/21/24. They acknowledged the findings. HR notified all staff on mandatory classes not completed. They will be completed by the date certain. All courses have been assigned to Oregon Care Partners and Relias to be completed by staff. HR will audit weekly for incomplete training and if not complete will notify the ED for further action. The ED will audit weekly for completion. OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 4 newly hired staff (#s 28, 30, and 31) demonstrated competency in abdominal thrust within 30 days of hire. This is a repeat citation. Findings include, but are not limited to: Staff training records were reviewed on 07/23/25. There was no documented evidence Staff 28 (MT/CG), Staff 30 (CG), and Staff 31 (CG), hired 06/18/25, 06/05/25, and 05/07/25, respectively, had demonstrated competency in abdominal thrust within 30 days of hire. A “First Aid for Choking” form had been signed by Staff 31 and Staff 3 (RN) but was not dated. The need for newly hired direct care staff to demonstrate competency in abdominal thrust was discussed with Staff 1 (Executive Director) and Staff 2 (Assistant Executive Director) on 07/24/25 9:55 am. They acknowledged the findings.”

“Based on interview and record review, it was determined the facility failed to ensure the re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to: C231, C252, C260, C270, C303, C362, C363, C372, C513, C530, C555, Z155, and H1510. Refer to C231, C252, C260, C270, C303, C362, C363, C372, C513, C530, C555, Z155, and H1510 OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) 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 interview and record review, it was determined the facility failed to ensure the re-licensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to: Refer to C156, C260, C270, C362, and Z140. Refer to C156, C260, C270, C362, and Z140 OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) 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 and interview, it was determined the facility failed to ensure all exterior accesses to the RCF common-use areas were maintained in good repair. Findings include, but are not limited to: The facility grounds were toured on 11/19/24. Railings and posts on the wraparound deck at the entrance to the RCF had large portions of peeling paint exposing bare and decaying wood. These findings were shared with Staff 1 (ED) and Staff 2 (Assistant ED) on 11/21/24 at 1:55 pm. They acknowledged the railings and posts were not in good repair. Railings and posts on wrap around deck at the entrance to the RCF have been added to our maintenance program, TEL's and completed. Monthly rounds will be done to check the exterior of the building. This will be recorded in TELs. Monthly Maintenance supervisor or designee. OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by:”

“Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: The interior of the facility was toured on 11/19/24. The following areas needed cleaning or repair:”

“Based on observation and interview, it was determined the facility failed to ensure soiled clothing and linens were laundered in a machine with a minimum rinse temperature of 140 degrees Fahrenheit or with a chemical disinfectant, and failed to ensure soiled linens and clothing were processed separate from regular linens and clothing and in a closed container. Findings include, but are not limited to: The facility laundry process was observed on 11/20/24 and staff were interviewed. The washing machines had general temperature settings but no device to determine the water temperature. Soiled linens were washed with laundry detergent, which was identified as lacking a chemical disinfectant, and Staff 6 (Housekeeping/Laundry Supervisor) confirmed that no chemical disinfectant was added to the soiled linen. Staff 24 (Housekeeping & Laundry) and Staff 14 (CG) reported in an interview on 11/20/24 at 10:50 am that soiled linen and laundry with fecal matter were washed in the hopper sink and placed in the designated five gallon bucket with a lid. They reported soiled linen and laundry with urine were placed in the large open laundry bins by color, with the regular linen and laundry. Staff 24 and Staff 14 stated they did not know that soiled laundry and linen meant laundry and linen contaminated by an individual’s bodily fluids. The need to process soiled linens and clothing separate from regular linens and clothing, keep soiled linens and clothing in closed containers, and use a chemical disinfectant when washing soiled linens and clothing unless the washer had a minimum rinse temperature of 140 degrees, was discussed with Staff 1 (ED) and Staff 2 (Assistant ED) on 11/21/24 at 1:50 pm. They acknowledged the findings. Oxivirtb (disinfectant,) was purchased and placed in the laundry locked cabinet to be used by staff Housekeeping supervisor will train staff on proper use of the Oxibirtb. Housekeeping supervisor will alert ED when the product needs ordered. This will be checked daily by the housekeeping supervisor. Executive director or designee. OAR 411-054-0200 (7)(b-d) Housekeeping and Laundry (b) HOUSEKEEPING AND SANITATION.(A) A RCF must have a secured janitor closet for storing supplies and equipment, with a floor or service sink.(B) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.(c) LAUNDRY FACILITIES. Laundry facilities may be located to allow for both resident and staff use, when a time schedule for resident-use is provided and equipment is of residential type. When the primary laundry is not in the building or suitable for resident-use, a RCF must provide separate resident-use laundry facilities. A CF is not required to provide resident-use laundry services.(A) Laundry facilities must be operable and at no additional cost to the resident.(B) Laundry facilities must have space and equipment to handle laundry-processing needs. Laundry facilities must be separate from food preparation and other resident-use areas.(C) On-site laundry facilities, used by staff for facility and resident laundry, must have capacity for locked storage of chemicals and equipment.(D) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.(d) SOILED LINEN PROCESSING. For the purpose of this rule, "soiled linens and soiled clothing," means linens or clothing contaminated by an individual's bodily fluids (for example, urine, feces, or blood).(A) There must be a separate area with closed containers that ensure the separate storage and handling of soiled linens and soiled clothing. There must be space and equipment to handle soiled linen and soiled clothing processing needs that is separate from regular linens and clothing.(B) Arrangement must provide a one-way flow of soiled linens and soiled clothing from the soiled area to the clean area and preclude potential for contamination of clean linens and clothing.(C) The soiled linen room or area, must include a flushing rim clinical sink with a handheld rinsing device and a hand wash sink or lavatory.(D) When washing soiled linens and soiled clothing, washers must have a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant is used.(E) Personnel handling soiled laundry must be provided with waterproof gloves.(F) Covered or enclosed clean linen storage must be provided and may be on shelves or carts. Clean linens may be stored in closets outside the laundry area.(G) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure soiled clothing and linens were laundered in a machine with a minimum rinse temperature of 140 degrees Fahrenheit or with a chemical disinfectant, and failed to ensure soiled linens and clothing were processed separate from regular linens and clothing and in a closed container. This is a repeat citation. Findings include, but are not limited to: The facility laundry process was observed on 07/21/25, and staff were interviewed. A water heater designated to the laundry room and washing machines maintained a temperature of 120 degrees Fahrenheit. Soiled linens were washed with laundry detergent, which was identified as lacking a chemical disinfectant, and Staff 6 (Housekeeping and Laundry Supervisor) and Staff 41 (Housekeeping and Laundry) confirmed that no chemical disinfectant was added to the soiled linen. Staff 41 reported in an interview on 07/21/25 at 1:30 pm that laundry with fecal matter, urine, and/or blood was washed in the utility sink and placed in the designated five-gallon bucket, which did not have a lid. Residents’ regular laundry and linens were placed in large, open bins and washed with soiled items of the same color. On 07/22/25, Staff 6 confirmed soiled laundry was not washed separately from regular laundry. The need to process soiled linens and clothing separate from regular linens and clothing, keep soiled linens and clothing in closed containers, and use a chemical disinfectant when washing soiled linens and clothing unless the washer had a minimum rinse temperature of 140 degrees, was discussed with Staff 1 (Executive Director) and Staff 25 (Maintenance Director) on 07/24/25 at 11:30 am. They acknowledged the findings.”

“Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. Findings include, but are not limited to: A tour of the facility on 11/19/24 identified the following:”

“Based on observation and interview, it was determined the facility failed to provide each individual the right to privacy in his or her own unit and to have personal information posted for multiple sampled and unsampled residents. Findings include, but are not limited to:”

“Based on record review and interview, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their unit. Findings include, but are not limited to: Review of records for Residents 3, 4, and 5 revealed no documented evidence the residents had been provided keys to their rooms or had been evaluated for the ability to manage keys to their rooms. An interview with Staff 1 (ED) and Staff 2 (Assistant ED) on 11/20/24 at 2:00 pm revealed residents in the MCC were not provided keys to their unit. The need to ensure all residents were provided keys to their units was discussed with Staff 1 and Staff 2 on 11/20/24 at 2:00 pm. They acknowledged the findings. Keys have been given to every resident. In memory care keys have been taped to the inside of the closet door. Residents have been informed. Housekeeping Supervisor will audit rooms for keys weekly using the room census form. The audit will be reviewed weekly for completion by ED or designee. The Exexutive director or designee will review audit. OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by: OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all residents who lived in the facility were provided a key to their unit. Findings include, but are not limited to: Multiple interviews conducted on 01/21/26 and 01/22/26 with unsampled residents in the MCC and RCF indicated they had not been provided with a key to their room and expressed a desire to have one. One resident in the MCC reported that another resident repeatedly entered his/her room without permission and stated he/she wanted a key to prevent uninvited entry. Another resident in the RCF reported he/she had experienced numerous items being stolen from his/her room, had never been provided with a key, and stated he/she wanted a key. In an interview on 01/22/26 at 09:44 am, Staff 1 (Executive Director) reported that only residents that stated they wanted a key to their unit were given keys. Staff 1 reported that no residents in the RCF part of the facility had asked for a key and that in the memory care unit keys had been taped in all closets but not always offered to the residents. There was no documented evidence that each resident had been provided a key to their unit. The need to ensure all residents were provided keys to their units was discussed with Staff 1 and Staff 2 (Assistant Executive Director) on 01/22/26 at 9:44 am. Staff acknowledged the findings. Keys have been made and given to all residents that wanted them. 2. A form has been made and added to residents record. 3. Keys will be offered at move in 4. Administrator or designee OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by:”

“Based on interview and record review, the facility failed to ensure the move-in evaluation addressed all required elements, including gender identity, for 1 of 1 resident (#7) whose move-in evaluation was reviewed. Findings include, but are not limited to: Refer to C 252. Refer to C252 OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (c) Each resident record must, before move-in and when updated, include the following information: (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name (B) Pronouns. (C) Gender identity. This Rule is not met as evidenced by:”

“Based on observation, interview, and record review, it was determined the licensee failed to provide administrative oversight to ensure the operation of the memory care community and the provision of person-centered care that promoted each resident’s dignity, independence, and comfort, including the supervision, training, and overall conduct of the staff. Findings include, but are not limited to: During the first revisit to the re-licensure survey of 11/21/24, conducted 07/21/25 through 07/25/25, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations and system failures. Refer to deficiencies in the report. Refer to C231, C252, C260, C270, C280, C303, C310, C372, H1510, Z155, Z164. OAR 411-057-0140(1) Administration Responsibilities (1) The licensee is responsible for the operation of the memory care community and the provision of person centered care that promotes each resident's dignity, independence, and comfort. This includes the supervision, training, and overall conduct of the staff. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight over the operation of the Memory Care Community. This is a repeat citation. Findings include, but are not limited to: During the second re-visit to the re-licensure survey of 11/21/24, conducted 01/20/26 through 01/22/26, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective as evidence by the failure to implement a plan of correction, ensure adequate oversight to correct deficiencies, and the issuance of two new citations. Refer to deficiencies in the report. Refer to C156, C260, C270, C362. OAR 411-057-0140(1) Administration Responsibilities (1) The licensee is responsible for the operation of the memory care community and the provision of person centered care that promotes each resident's dignity, independence, and comfort. This includes the supervision, training, and overall conduct of the staff. This Rule is not met as evidenced by:”

“Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C231, C362, C363, C372, C510, C513, C530 and C555. Refer to responses in C231, C362, C363, C372, 510, C513, C530, and C555 OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: ?Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to: C156, C160, C231, C362, C363, C372, C513, C530, and C555 Refer to C156, C160, C231, C362, C363, C372, C513, C530, and C555 OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C156, C242, and C362. Refer to C 156, C 242 and C 362. OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by:”

“Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly-hired staff (#s 15, 16, 17 and 21) completed all required pre-service orientation training prior to beginning their job responsibilities, 3 of 3 newly-hired direct care staff (#s 15, 17 and 21) completed all required competency training within 30 days of hire, and 1 of 3 long-term staff (#19) completed annual infectious disease training. Findings include, but are not limited to: Training records were reviewed on 11/21/24 with Staff 8 (Business Office Manager). The following were identified:”

“Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C252, C260, C270, C282, C302, C303, C305 and C325. Refer to C252, C260, C270, C282, C302, C303, C305, and C325. OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to: C252, C260, C270, C280, C303, and C310. Refer to C252, C260, C270, C280, C303, and C310. OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C260 and C270. Refer to C 260 and C 270. OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by:”

“based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide meaningful activities that promoted or helped sustain the physical and emotional well-being of residents and provide person-centered activities during residents’ waking hours for 3 of 3 sampled residents whose records were reviewed and multiple unsampled residents. In addition, the facility failed to address all required elements in activity evaluations and to create an individualized activity plan based on the evaluation for 2 of 3 sampled residents whose activity evaluations and plans were reviewed. Findings include, but are not limited to:”

“Based on observation and interview, it was determined the facility failed to provide access to a secured outdoor space which allowed residents to enter and return without staff assistance, except when indicated by OAR 411-057-0170(5)(e). Findings include, but are not limited to: On 11/19/24 at 10:00 am staff were observed using a code to open the door leading to the MCC yard to take a group of residents outside. At 10:35 am Staff 23 (MT) reported that residents were not allowed outside without staff “because we don’t want them going over the fence.” The need to ensure residents have access to secured outdoor spaces without staff assistance was discussed with Staff 1 (ED) on 11/20/24 at 10:35 am. She acknowledged the findings. The code was removed from the door and residents are able to gain access to the court yard any time they choose to do so. It was corrected by removing the code. The code will not be placed on the door in the future. Safety Coordinator will check weekly to ensure a code is not added to the door. OAR 411-057-0160(g) Outside Area (g) Access to secured outdoor space and walkways which allow residents to enter and return without staff assistance, except when indicated by OAR 411-057-0170(5)(e). This Rule is not met as evidenced by:”

“Based on observation and interview, the facility failed to ensure fences surrounding the perimeter of the outdoor recreation area were no less than six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition. Findings include, but are not limited to: During the acuity interview on 07/21/25, facility staff stated that an unsampled resident had eloped by climbing up and over the chain-link fence in the facility’s outdoor recreation area in 05/2025. The facility stated vertical slats had since been installed in the chain-link to reduce the risk of resident elopement. They confirmed that the resident currently resides in the MCC, in addition to at least three other residents with history or risk of elopement. On 07/21/25 at 3:30 pm, the outdoor recreation area was observed to have an approximately 50 foot stretch of sidewalk enclosed with chain-link fencing which did not have slats installed. The chain-link fence was five feet in height. The fence failed to be six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition. On 07/21/25 at 4:15 pm Staff 1 (Executive Director) and Staff 2 (Assistant Executive Director) acknowledged the findings. At 4:45 pm, they stated that Staff 25 (Maintenance Director) would be installing modifications to ensure the fence reached six feet in height that evening, and that staff would stay in the courtyard to ensure residents did not elope prior to the fence being modified. On 07/22/25 at 8:19 am, the outdoor recreation area pathway identified above was observed to have a smooth wooden fence which reached five feet and seven inches in height. Poultry netting was visible behind the wooden fence as it was previously located on top of the chain link fence, but was not constructed in a way to reduce the risk of elopement. The fence along the 50 foot stretch of pathway continued to be less than six feet in height. The need to ensure fences surrounding the perimeter of the outdoor recreation area were no less than six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition, was reviewed with Staff 1, Staff 2 and Staff 3 (RN) on 07/25/25 at 9:30 am. They acknowledged the findings.”

“The findings of the kitchen inspection, conducted 06/10/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. The findings of the kitchen inspection, conducted 06/10/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. The findings of the revisit to the kitchen inspection of 06/10/24, conducted 10/23/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. The findings of the revisit to the kitchen inspection of 06/10/24, conducted 10/23/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.”

“Based on observation, interview, and record review, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000.  Findings include, but are not limited to: a. Observations of the main facility kitchen and memory care kitchenette, food storage areas, food preparation, and food service on 04/10/24 from 10:15 pm through 2:30 pm revealed splatters, spills, drips, dust and debris noted on: - Fan in dish room area; - Ice machine with black, shiny substance on interior; - Industrial can opener and housing; and - cupboard storing clean single use paper napkins. b. The following items were found in need of repair; - Multiple holes around pipes in the basement dry food storage. c. Staff were unable to produce the correct strips for sanitizing step of dish machine. Staff were not consistently monitoring the sanitation of the dish machine to ensure adequate sanitation was being maintained. d. Red sanitizing bucket was not at the correct concentration of sanitizing agent. Staff were asked how frequent the bucket was changed and staff indicated once a day. The requirement is every two hours or when soiled. Staff made a new bucket and sanitizing concentration was at proper levels. e. Multiple items in dry storage were opened and were not dated when opened. f. Multiple items were not dated in reach in refrigerators when opened. Multiple cold food items did not contain use by dates. A bag of personal raised chicken eggs were stored in the reach in refrigerator where resident food was stored. There was not a date or label. g. Multiple pieces of used cardboard was found in reach in freezers being used as shelf liners. These pieces of cardboard were noted to be soiled. h. The designated person in charge was not able to correctly discuss proper reheating temperatures or the proper cooling of potentially hazardous foods. The designated PIC was also not able to describe the illnesses identified in the food code that food workers must be excluded for or reported to local health department. i. Multiple resident trays were delivered to resident rooms without being covered and protected from potential contamination. j. Facility did not have a three compartment sink for effective washing and sanitizing of dishes/equipment when/if ware washer was not operational. Staff validated census capacity was greater than 17 residents. Staff 2 (Person In charge) toured the kitchen with the surveyor. They acknowledged the above items. At approximately 2:30 pm Staff 1 (Administrator) and the surveyor reviewed areas of concern. Staff 1 acknowledged the above findings. Based on observation, interview, and record review, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000.  Findings include, but are not limited to: a. Observations of the main facility kitchen and memory care kitchenette, food storage areas, food preparation, and food service on 04/10/24 from 10:15 pm through 2:30 pm revealed splatters, spills, drips, dust and debris noted on: - Fan in dish room area; - Ice machine with black, shiny substance on interior; - Industrial can opener and housing; and - cupboard storing clean single use paper napkins. b. The following items were found in need of repair; - Multiple holes around pipes in the basement dry food storage. c. Staff were unable to produce the correct strips for sanitizing step of dish machine. Staff were not consistently monitoring the sanitation of the dish machine to ensure adequate sanitation was being maintained. d. Red sanitizing bucket was not at the correct concentration of sanitizing agent. Staff were asked how frequent the bucket was changed and staff indicated once a day. The requirement is every two hours or when soiled. Staff made a new bucket and sanitizing concentration was at proper levels. e. Multiple items in dry storage were opened and were not dated when opened. f. Multiple items were not dated in reach in refrigerators when opened. Multiple cold food items did not contain use by dates. A bag of personal raised chicken eggs were stored in the reach in refrigerator where resident food was stored. There was not a date or label. g. Multiple pieces of used cardboard was found in reach in freezers being used as shelf liners. These pieces of cardboard were noted to be soiled. h. The designated person in charge was not able to correctly discuss proper reheating temperatures or the proper cooling of potentially hazardous foods. The designated PIC was also not able to describe the illnesses identified in the food code that food workers must be excluded for or reported to local health department. i. Multiple resident trays were delivered to resident rooms without being covered and protected from potential contamination. j. Facility did not have a three compartment sink for effective washing and sanitizing of dishes/equipment when/if ware washer was not operational. Staff validated census capacity was greater than 17 residents. Staff 2 (Person In charge) toured the kitchen with the surveyor. They acknowledged the above items. At approximately 2:30 pm Staff 1 (Administrator) and the surveyor reviewed areas of concern. Staff 1 acknowledged the above findings. a. Fan in dish room, ice maker and can opener are on the weekly dish washer cleaning list. Napkins are in a plastic container with lid. b. Holes in the basement were fixed by maintenance staff. Kitchen manager had a meeting with the kitchen staff to talk about sanitizing strips and sanitizing buckets. Signs  were put up on the wall as reminders. Kitchen Manager will make more frequent checks to dry storage room and refrigerator, so items are properly labeled and covered. The cardboard was removed and plastic containers will be used when needed. The designated person in charge will take the Save Serve Certification Class. Kitchen Staff will be reminded to cover any tray that is left in the kitchen or dining room. When dishwasher is out of order, we use a large plastic tub and fill it with sanitizer water. a. Fan in dish room, ice maker and can opener are on the weekly dish washer cleaning list. Napkins are in a plastic container with lid. b. Holes in the basement were fixed by maintenance staff. Kitchen manager had a meeting with the kitchen staff to talk about sanitizing strips and sanitizing buckets. Signs  were put up on the wall as reminders. Kitchen Manager will make more frequent checks to dry storage room and refrigerator, so items are properly labeled and covered. The cardboard was removed and plastic containers will be used when needed. The designated person in charge will take the Save Serve Certification Class. Kitchen Staff will be reminded to cover any tray that is left in the kitchen or dining room. When dishwasher is out of order, we use a large plastic tub and fill it with sanitizer water. There are no detail notes for this visit.”

“Based on observations and interviews, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 240. Based on observations and interviews, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 240. see C 240 see C 240 There are no detail notes for this visit.”

“The findings of the on-site investigation, conducted 04/02/24, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT:            Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse The findings of the on-site investigation, conducted 04/02/24, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT:            Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse”

“Based on interview, and record review, conducted during a site visit on 04/02/24, it was confirmed the facility failed to fully implement an Acuity Based Staffing Tool (ABST). Findings include, but are not limited to: A review of the facility's Census Room List, dated 03/29/24, indicated the facility is home to 51 residents. A review of the facility's ABST  indicated there were 52 current residents. Sunny Lane residents indicated seven of the 11 entered residents were not updated within the last 90 days for quarterly review, and one resident was last updated as of 07/2022. In an interview on 04/12/24 via over the telephone, Staff 1 (ED) confirmed s/he did not set up the tool and was unaware all residents needed to be updated quarterly. The above information was shared with Staff 1 on 04/12/24 via over the telephone. S/he acknowledged the findings. It was confirmed the facility failed to fully implement an Acuity Based Staffing Tool and was consistently staffing below the levels indicated by the tool. Based on interview, and record review, conducted during a site visit on 04/02/24, it was confirmed the facility failed to fully implement an Acuity Based Staffing Tool (ABST). Findings include, but are not limited to: A review of the facility's Census Room List, dated 03/29/24, indicated the facility is home to 51 residents. A review of the facility's ABST  indicated there were 52 current residents. Sunny Lane residents indicated seven of the 11 entered residents were not updated within the last 90 days for quarterly review, and one resident was last updated as of 07/2022. In an interview on 04/12/24 via over the telephone, Staff 1 (ED) confirmed s/he did not set up the tool and was unaware all residents needed to be updated quarterly. The above information was shared with Staff 1 on 04/12/24 via over the telephone. S/he acknowledged the findings. It was confirmed the facility failed to fully implement an Acuity Based Staffing Tool and was consistently staffing below the levels indicated by the tool.”

“The findings of the on-site investigation, conducted 04/02/24, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT:            Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse The findings of the on-site investigation, conducted 04/02/24, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT:            Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse”