OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the licensee failed to provide effective oversight for the operation of the facility and to ensure the quality of services rendered in the facility. Findings include, but are not limited to: During the change of ownership survey, conducted 01/27/25 through 01/30/25, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity of the citations. 1. A situation was identified which constituted an immediate threat to the health and safety of the residents in the following area: C 555: OAR 411-054-0200 (11-13) Call System, Exit Door Alarms, Phones, TV, or Cable. The facility developed and implemented an immediate plan of correction during the survey to address the threat to residents' safety. 2. Refer to deficiencies in the report.

Executive Director (ED) will educate all managers on this POC and their responsibilities in this POC by 2/24/2025 ED is responsible for daily follow up at stand up with items on this POC ED will educate staff on call light system response & appropriate equipment usage. Training will be added to New Employee Orientation. ED is responsible to review call light times daily and address identified issues daily. One regional team member will be onsite two times time per month to audit and spot check x 3 months.

OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals. This Rule is not met as evidenced by:

OAR 411-054-0025 (7) Facility Administration: Policy & Procedure (7) POLICIES AND PROCEDURES. The facility must develop and implement written policies and procedures that promote high quality services, health and safety for residents, and incorporate the community based care principles of individuality, independence, dignity, privacy, choice, and a homelike environment. The facility must develop and implement: (a) A policy on the possession of firearms and ammunition within the facility. The policy must be disclosed in writing and by one other means of communication commonly used by the resident or potential resident in his or her daily living. (b) A written policy that prohibits sexual relations between any facility employee and a resident who did not have a pre-existing relationship. (c) Effective methods of responding to and resolving resident complaints. (d) All additional requirements for written policies and procedures as established in OAR 411-054-0012 (Requirements for New Construction or Initial Licensure), OAR 411-054-0040 (Change of Condition and Monitoring), OAR 411-054-0045 (Resident Health Services), and OAR 411-054-0085 (Refunds and Financial Management). (e) A policy on smoking. (A) The smoking policy must be in accordance with: (i) The Oregon Indoor Clean Air Act, ORS 433.835 to 433.875; (ii) The rules in OAR chapter 333, division 015; and (iii) Any other applicable state and local laws. (B) The facility may designate itself as non-smoking. (f) A policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner. The policy must include information regarding the collection of medical and forensic evidence that must be obtained within 86 hours of the incident. (g) A policy on facility employees not receiving gifts or money from residents. (h) Protocols for preventing and controlling infection, as described in OAR 411-054-0050. (i) LGBTQIA2S+ Nondiscrimination Notice: “(Name of care facility) does not discriminate and does not permit discrimination, including but not limited to bullying, abuse or harassment, based on an individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status, or based on an individual’s association with another individual on account of the other individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status. If you believe you have experienced this kind of discrimination, you may file a complaint with the Oregon Department of Human Services at (provide current contact information).” (j) ABST Policy for accurate and consistent implementation of the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to: A review of Resident Council Meeting Notes dated 10/15/24, 12/10/24, and 01/07/25 identified the following resident concerns: On 10/15/24, staff documented residents stating: * "We are bored, we need more socialization”; * “We want family outings and hotdogs”; * “We want more poker nights and play cards”; * “We would like a pizza night and [non-alcoholic] mai tais”; * “We need to get out more and do, we need models and tinker toys to keep us busy”; * “More movie nights”; * “Ladies would like to put together paper flowers, go Christmas shopping”; * “All residents stated they would like to incorporate food into an activity so they can make things they like instead of hoping they get it on the menu”; * “Need books, such as westerns, mystery, and romance”; * “Need more music and dances”; * “We would like soup of the day not just at dinner time”; * “Residents stated they would like more options with food, they would like hot dogs instead of hamburgers all the time”; * “Memory care said they are not getting their snacks”. Staff documentation on 12/10/24 was as follows: * “Staff need to sanitize hands prior to entering rooms and upon leaving rooms”; * “Hand sanitizer wall mounts are empty; residents want to remain healthy as possible and would like to get the wall mounts filled so staff can utilize them”; and * “Bus needs to be painted or rewrapped as you can still see Farmington Square as the community”. On 01/07/25, staff documented the following concerns: * “A resident brought to the attention that when ringing for assistance no one comes. [S/He] said [s/he] thinks the system is broken and what can we do to be able to get the assistance that the residents need”; * “It was stated the [call] system wasn’t working for a week and they had an interim plan of 15-minute round checks to visually lay eyes on each resident.” * “A resident pressed [his/her] wrist pendant to see how long it would take care staff to respond, this was at the beginning of the meeting [2:00 pm] at the end of the meeting [3:00 pm] a [CG] came.” “[CG] was informed that the pendant had been activated since the beginning of the meeting and that it was not appropriate to take so long to respond.” “[CG] reported the phone was dead, so it was charging”; * “Residents feel they are forgotten by staff when they are sick and trying to minimize exposing others by remaining in rooms”; * “Cottage A is upset as they are not getting their snacks, often times snacks are not furnished or available”; and * “Residents stated laundry is challenging and items don’t always make it back to the residents”. There was no documented evidence the above concerns identified during the Resident Council Meetings had been addressed, responded to, or resolved. In an interview on 01/28/25 at 12:28 pm, Staff 1 (ED) acknowledged the lack of documented follow-up response to complaints or suggestions from Resident Council Meetings. She stated her plan moving forward was to document resident complaints and how the facility attempted to resolve complaints. The need to improve the facility's method for responding to and resolving resident complaints was reviewed with Staff 1 and Staff 2 (Regional Director of Operations) on 01/28/25. They acknowledged the findings.

ED will review all Resident Council Notes within 24 hours after monthly Resident Council Meetings ED will identify concerns and note them in Grievance Binder ED will address concerns with appropriate Team Member within 48 hour of Resident Council Meeting ED will follow up with Team Member daily to during Stand Up Meeting to ensure concerns are resolved ED will file completed Grievance form in Completed Grievance binder

OAR 411-054-0025 (7) Facility Administration: Policy & Procedure (7) POLICIES AND PROCEDURES. The facility must develop and implement written policies and procedures that promote high quality services, health and safety for residents, and incorporate the community based care principles of individuality, independence, dignity, privacy, choice, and a homelike environment. The facility must develop and implement: (a) A policy on the possession of firearms and ammunition within the facility. The policy must be disclosed in writing and by one other means of communication commonly used by the resident or potential resident in his or her daily living. (b) A written policy that prohibits sexual relations between any facility employee and a resident who did not have a pre-existing relationship. (c) Effective methods of responding to and resolving resident complaints. (d) All additional requirements for written policies and procedures as established in OAR 411-054-0012 (Requirements for New Construction or Initial Licensure), OAR 411-054-0040 (Change of Condition and Monitoring), OAR 411-054-0045 (Resident Health Services), and OAR 411-054-0085 (Refunds and Financial Management). (e) A policy on smoking. (A) The smoking policy must be in accordance with: (i) The Oregon Indoor Clean Air Act, ORS 433.835 to 433.875; (ii) The rules in OAR chapter 333, division 015; and (iii) Any other applicable state and local laws. (B) The facility may designate itself as non-smoking. (f) A policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner. The policy must include information regarding the collection of medical and forensic evidence that must be obtained within 86 hours of the incident. (g) A policy on facility employees not receiving gifts or money from residents. (h) Protocols for preventing and controlling infection, as described in OAR 411-054-0050. (i) LGBTQIA2S+ Nondiscrimination Notice: “(Name of care facility) does not discriminate and does not permit discrimination, including but not limited to bullying, abuse or harassment, based on an individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status, or based on an individual’s association with another individual on account of the other individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status. If you believe you have experienced this kind of discrimination, you may file a complaint with the Oregon Department of Human Services at (provide current contact information).” (j) ABST Policy for accurate and consistent implementation of the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. This Rule is not met as evidenced by:

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview, and record review, it was determined the facility failed to ensure incidents were investigated and when abuse could not be immediately ruled out, reported to the local SPD (Seniors and People with Disabilities) office for 4 of 5 sampled residents (#s 1, 3, 4, and 5) who were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 11/2024 with diagnoses including Alzheimer’s disease and dementia with psychosis. Observations of the resident and interviews with staff were conducted. Resident 3's service plan, Observation notes, dated 11/26/24 through 01/27/25, and incident reports, dated 12/04/24 through 01/22/25, were reviewed and revealed the following: * 01/02/25: Staff found the resident on the floor in another resident’s unit. When staff asked Resident 3 what happened, the resident stated that s/he didn’t remember. It was not clear if the resident sustained any injuries. * 01/22/25: Staff found the resident in his/her bedroom floor. Staff documented that Resident 3 “expressed some pain” in his/her “left hip” and “left elbow.” The incidents did not have a thorough investigation that ruled out abuse or suspected abuse. On 01/29/25 at 12:17 pm, Staff 1 (ED) verified the investigations were not complete and they had not been reported to the local SPD office. On 01/29/25 at 5:11 pm, Staff 1 provided documentation that both incidents had been reported to the local SPD office. The need to ensure incidents were immediately investigated and if abuse or suspected abuse could not be ruled out, the incidents were reported to the local SPD office was discussed with Staff 1 on 01/30/25 at 12:33 pm. She acknowledged the findings. 2. Resident 5 was admitted to the facility in 03/2019 with diagnoses including dementia. Interviews with staff, and review of the resident's 10/31/24 service plan, and 11/06/24 through 01/27/25 interim service plans, progress notes, and incident investigations were completed. The following was identified: On 01/21/25, Resident 5’s progress note following a hospice visit included “discolored wrists” The hospice visit note included documentation indicating the resident had discolorations to both wrists. On 01/28/25 survey requested a copy of the incident investigation. Staff 1 (ED) reported there had not been an incident report or immediate investigation completed for the discolorations to Resident 5’s wrists, and it had not been reported to the local SPD office. The need to ensure all incidents and injuries of unknown cause were reported to local SPD office was discussed with Staff 1, and Staff 2 (Regional Director of Operations) on 01/28/25. They acknowledged the findings. The facility was instructed to report the injury of unknown cause to the local SPD office on 01/28/25. Proof of reporting was received from the facility 01/28/25. 3. Resident 1 was admitted to the facility in 05/2024 with diagnoses including vascular dementia. A review of the resident's facility record, including Observation notes dated 10/14/24 through 01/27/25, and Temporary Service Plans were completed, and staff were interviewed. The following was identified: * 10/21/24: Staff documented in a progress note, the resident "was in bed with another resident"; and * 10/24/24: A progress note indicated the resident was bothering another resident, pulling on the other resident’s jacket, and was aggressive towards the other resident. There was no documented evidence the above incidents were promptly investigated at the time they occurred to rule out abuse, nor that they were reported to the local SPD office if abuse could not be ruled out. On 01/28/25, Staff 1 (ED) confirmed investigations were not promptly completed. Survey requested the facility report the incidents to the local SPD office. On 01/30/25 at 12:24 pm, verification was received of reporting the incidents to the local SPD office. The need to ensure all incidents of abuse or suspected abuse were immediately reported to the local SPD office and were promptly investigated was discussed with Staff 1 and Staff 2 (Regional Director of Operations) on 01/30/25. They acknowledged the findings. 4. Resident 4 was admitted to the facility in 09/2024 with diagnoses including dementia. Observations of the resident and interviews with staff were conducted. Resident 4's clinical records were reviewed and revealed the following: * 12/31/24: A progress note indicated the resident had swelling to his/her upper eye lid. There was no documented evidence of an immediate investigation as to how the injury occurred to rule out abuse or suspected abuse. * 01/09/25: A progress note indicated the resident was experiencing burning, discomfort, and swelling in his/her genital area. There was no documented evidence of an immediate investigation as to how the injury occurred to rule out abuse or suspected abuse. On 01/30/25 at approximately 11:00 am, Staff 1 (ED) verified there was no evidence of investigations which ruled out abuse or suspected about. On 01/30/25, the need to ensure an immediate investigation after injuries of unknown cause were identified to rule out abuse or suspected abuse was discussed with Staff 1 (ED). She acknowledged the findings. At approximately 3:20 pm survey received confirmation the incidents had been reported to the local SPD office.

ED will complete abuse/neglect/reporting training by 2/28/2025 All incidents were reported while survey team was on site. All staff will complete abuse/neglect training. The Business Office Manager (BOM)/designee will create a tracker list and monitor for completeness. ED/designee will investigate and self report to APS as required any report of potential abuse/neglect as required. This will be monitored by the RN Delegate 1 day/week x 3 months, 2 days/week or until compliance is achieved. This will be monitored by review of incident reports, progress notes, and shift report logs daily during Clinical Huddle.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by:

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs; This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide a daily program of social and recreational activities based upon 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: During the survey, conducted 01/27/25 through 01/30/25, observations were made in all three resident-occupied buildings (Cottages A, B, and C). Residents in Cottages A, B, and C were observed staying in their rooms, sitting in chairs sleeping, looking around, and/or exit seeking throughout the survey. The only scheduled activity observed during survey was on 01/29/25 at 1:00 pm, when Bingo was played in Cottage A, with multiple residents in attendance. The survey team did not consistently observe a daily program of social and recreational activities, which created opportunities for participation for the community at large. On 01/29/25, the need to ensure a daily activity program of social and recreational activities that were based on individual and group interests, physical, mental and psychosocial needs, and created opportunities for active participation in the community at large was discussed with Staff 1 (ED). She acknowledged the findings.

Resident Experience Team to attend Life Enrichment Training through OCP on 3/7/2025 ED/Resident Experience Director/Designee will be reeducated on activities/programming and following the calendar of daily programming by National Program Director by 3/07/2025. ED/Resident Experience Director/Designee will reeducate all staff on programming and activity calendar by 3/15/2025. ED/Designee will audit activities in all community houses daily x4weeks then weekly x3 months until compliance is met. Results of audits will be reported to Continuous Quality Improvement committee next scheduled meeting

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs; This Rule is not met as evidenced by:

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 assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, the facility failed to ensure evaluations were updated quarterly and reflective of the residents’ current status and condition for 2 of 6 sampled residents (#s 1 and 8) whose evaluations were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 05/2024 with diagnoses including vascular dementia and a fractured left tibia. Resident 1’s quarterly evaluation was completed on 12/25/24. The evaluation failed to be reflective of the resident's current status and condition in the following areas: * Mental health status including behavioral or mood problems and effective non-drug interventions; * Sexual activity with another resident; * Hospice admission; * Level of assistance required for ADLs; * Pain, including pharmaceutical and non-pharmaceutical interventions; and * Skin condition. On 01/30/25, the need to ensure the quarterly evaluation was reflective of the resident's condition was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings. 2. Resident 8 was admitted to the facility in 09/2023 with diagnoses including dementia and type II diabetes. a. The most recent quarterly evaluation for Resident 8 was completed on 04/18/24. The subsequent quarterly evaluations, due on 07/17/24, 10/15/24, and 01/15/25 were not completed. b. The current evaluation failed to be reflective of the resident's current condition in the following areas: * Sleep patterns; * Recent ER visits; * Sexual activity with another resident; * Resident-to-resident physical altercation; * Pain, pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort; * Skin condition; and * Fall risk or history. On 01/30/25, the need to ensure quarterly evaluations were completed timely and were reflective of the resident's current condition was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings.

Residents #1 and #8 service plans were updated by the LPN on 2/6/2025 to capture details and all requirements to meet needs. An audit of all evaluation due dates will be completed by the ED//Designee. The ED/Designee will audit all evaluations/service plans to ensure that all required items are captured with input from care staff, programming staff, resident and families. A weekly audit of evaluation/service plan dates will be done by the ED/Designee bi-weekly x 4 and then monthly so that evaluations/service plans are completed prior to move in, within 30 days, quarterly and with changes of condition.

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 assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by:

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) 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 updated at least quarterly, reflective of residents' current care needs and preferences, provided clear direction regarding the delivery of services, and/or were implemented for 6 of 9 sampled residents (#s 1, 2, 3, 4, 5 and 8) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 5 moved into the facility in 03/2019 and had diagnoses including dementia. The resident's current service plan, dated 10/31/24, was reviewed, observations were made, and interviews were conducted. The service plan was not reflective of the resident's needs and preferences, and did not provide clear instruction to staff in the following areas: * Use of divider plate for meals; * Air mattress overlay on bed; * Side rails with instructions; and * Specialty wheelchair with instructions. The need to ensure service plans were reflective of resident needs and preferences and provided clear direction to staff was discussed with Staff 1 (ED), and Staff 2 (Regional Director of Operations) on 01/29/25. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 12/2022 with diagnoses including cerebral palsy. Review of the resident’s clinical records, including the most recent service plan, dated 12/23/24, indicated s/he needed a modified dietary texture that included nectar thick liquids. On 01/29/25 at approximately 8:45 am, the resident was observed drinking a glass of water which was regular consistency, and not nectar thick. Resident 2 began to cough while drinking the regular consistency water. Staff 27 (Cook) overheard Resident 2 struggling with their water and quickly switched the resident’s water for a glass of nectar thick water. On 01/30/25, the need to ensure the service plan was being implemented was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings. 3. Resident 4 was admitted to the facility in 09/2024 with diagnoses including dementia. Observations, interviews and review of the current service plan, dated 12/28/24, revealed the service plan was not reflective of the resident's current status and/or lacked clear instructions to staff in the following areas: * Transfers; * Toileting; and * Dressing. On 01/30/25, the need to ensure service plans were reflective of resident care needs and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings. 4. Resident 1 was admitted to the facility in 05/2024 with diagnoses including vascular dementia and a fractured tibia. The resident's 09/24/24 service plan was reviewed, observations were made of the resident, and interviews with staff occurred throughout the survey. The service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas: * Diagnosis of skin cancer; * Hospice services and schedule; * Behavioral changes and interventions; * Sexual activity with another resident; * Two person assist with transfers and use of gait belt; * Incontinence care provided in bed; * Current skin condition and treatment; and * Pain areas and treatment. On 01/30/25, the need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings. 5. Resident 8 was admitted to the facility in 09/2023 with diagnoses including dementia and type 2 diabetes. The resident’s 04/18/24 service plan was reviewed, observations were made of the resident, and interviews with staff occurred throughout the survey. The service plan had not been updated quarterly, was not reflective of the resident’s current needs, and did not provide clear direction to staff in the following areas: * Sleep disturbance and caregiving instructions; * Sexual activity with another resident; * Resident-to-resident physical altercation and interventions; * Pain status; and * Recent falls and interventions to minimize falls. On 01/30/25, the need to ensure resident service plans were updated quarterly, reflective of the resident’s current care needs, and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings. 6. Resident 3 was admitted to the facility in 11/2024 with diagnoses including Alzheimer’s disease, dementia with psychosis, and anxiety. The resident’s 11/20/24 service plan was reviewed, observations were made of the resident, and interviews with staff occurred throughout the survey. The service plan was not reflective of the resident’s current needs, did not provide clear direction to staff, and/or was not implemented in the following areas: * Confusion and how that affected communication and orientation; * How Resident 3 exhibited aggression; * Redirection to a low stimulus environment when the resident was exhibiting restlessness or anxiety; * Signs of anxiety, agitation, and overstimulation; * Where the key to his/her unit was located; * The use of glasses and assistance needed from staff; * Behavior interventions; * Assistance needed for ADLs; * Activity preferences; * Fall interventions; and * Specific instruction to staff relating to if s/he chose not to eat the meal served. The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and/or were implemented was discussed with Staff 1 (ED) on 01/30/25 at 12:33 pm. She acknowledged the findings.

Residents #1(2/6/2025), #2 (2/13/2025), #3 (2/6/2025), #4 (2/11/2025), and #8(2/6/2025) Service plans were updated by the Regional Director of Health Services on the dates in parentheses to provide clear instruction to the care staff. Resident #5's service plan will be updated by the LPN by 2/25/2025. An audit of all evaluation due dates will be completed by the ED/Designee. The ED/Designee will audit all evaluations/service plans to ensure that all required items are captured with input from care staff, programming staff, resident and families. A weekly audit of evaluation/service plan dates will be done by the ED/Designee bi-weekly x 4 and then monthly so that evaluations/service plans are completed prior to move in, within 30 days, quarterly and with changes of condition and they are readily available to staff. Weekly Audit with Department Head Team to ensure Service Plans are accurately reflecting current needs & preferences, review one resident weekly.

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) 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:

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to determine and document what action or intervention was needed for a resident following a short-term change of condition, document on the progress of the condition at least weekly until resolution and ensure documentation of interventions was made part of the resident record for 9 of 9 sampled residents (#s 1, 2, 3, 4, 5, 6, 7, 8 and 9) with changes of condition or who required monitoring. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 09/2024 with diagnoses including dementia. Resident 4’s clinical record was reviewed for changes of condition and revealed the following: * 10/29/24: The resident was experiencing a rash to his/her groin area; * 12/03/24: Staff documented the resident “just wanted to die”; * 12/31/24: Resident 4 was experiencing swelling to his/her upper eyelid; * 01/08/25: The resident was found on the floor from a non-injury fall; and * 01/09/25: Resident 4 was experiencing burning, discomfort, and swelling in his/her genital area. There was no documented evidence the facility determined and documented actions or interventions for the changes of condition, those actions or interventions were communicated to staff on each shift, and/or the change was monitored through resolution. On 01/30/25, the need to ensure residents who experienced a change of condition had resident specific interventions and were monitored through resolution was discussed Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings. 2. Resident 2 was admitted to the facility in 12/2022 with diagnoses including cerebral palsy. Resident 2’s clinical record was reviewed for changes of condition and revealed the following: * 12/01/24: The resident was placed on alert charting for exposure to COVID. There was no documented evidence the resident’s condition had resolved. On 01/30/25, the need to ensure residents who experienced a change of condition had documented evidence of resolution was discussed Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings. 3. Resident 3 was admitted to the facility in 11/2024 with diagnoses including Alzheimer's disease and dementia with psychosis. The resident’s Observation notes, dated 11/26/24 through 01/27/25, and Temporary Service Plans, dated 11/26/24 through 01/24/25, were reviewed and staff were interviewed. The following changes of condition were identified: * 11/25/24: Admission to the community; * 12/02/24: Exposure to Covid; * 12/04/24: Fainting episode resulting in a fall and hospital admission; * 12/09/24: Fall; * 12/10/24: Discontinuation of a medication; * 12/12/24: Elopement attempt; * 12/13/24: Elopement attempt; * 12/13/24: Suicide ideation; * 12/15/24: Suicide ideation; * 12/20/24: Resident to resident altercation; * 12/25/24: Addition of a medication; * 01/02/25: Fall; * 01/09/25: Addition of two medications; * 01/21/25: Sexual behavior; * 01/22/25: Decrease of a medication; and * 01/22/25: Fall. There was no documented evidence the facility determined and documented actions or interventions for the changes of condition, those actions or interventions were communicated to staff on each shift, and/or the change was monitored through resolution. The need to ensure the facility determined and documented actions or interventions for the changes of condition, communicated the actions or interventions to staff on each shift, and/or the change was monitored through resolution was discussed with Staff 1 (ED) on 01/30/25 at 12:33 pm. She acknowledged the findings. 4. Resident 6 was admitted to the facility in 11/2024 with diagnoses including dementia. The resident’s Observation notes, dated 11/06/24 through 12/18/24, service plan, dated 10/29/24, and the initial evaluation, dated 10/29/24, were reviewed. The following changes of condition were identified: * 11/06/24: Admission to the community; and * 12/02/24: Exposure to Covid. There was no documented evidence the facility determined and documented actions or interventions for the changes of condition, those actions or interventions were communicated to staff on each shift, and/or the change was monitored through resolution. The need to ensure the facility determined and documented actions or interventions for the changes of condition, communicated the actions or interventions to staff on each shift, and/or the change was monitored through resolution was discussed with Staff 1 (ED) on 01/30/25 at 12:33 pm. She acknowledged the findings. 5. Resident 7 was admitted to the facility in 08/2024 with diagnoses including Alzheimer’s disease and type 2 diabetes. The resident’s observation notes, dated 10/11/24 through 01/27/25, and the 12/10/24 service plan was reviewed. The following changes of condition were identified: * 10/11/24: Decrease in medication; * 12/02/24: Exposure to Covid; * 01/08/25: Emergency room visit resulting in a diagnosis of bronchitis and prescribing Zithromax (an antibiotic); and * 01/10/25: Discontinuation of a PRN order for insulin. There was no documented evidence the facility determined and documented actions or interventions for the changes of condition, those actions or interventions were communicated to staff on each shift, and/or the change was monitored through resolution. The need to ensure the facility determined and documented actions or interventions for the changes of condition, communicated the actions or interventions to staff on each shift, and/or the change was monitored through resolution was discussed with Staff 1 (ED) on 01/30/25 at 12:33 pm. She acknowledged the findings. 6. Resident 1 was admitted to the facility in 05/2024 with diagnoses including vascular dementia and a fractured left tibia. The resident's 09/24/24 service plan, Temporary Service Plans and progress notes, dated 10/14/24 through 01/27/25, were reviewed and identified the following: * 10/14/24: A progress note indicated the resident had an “old scratch/bump on [his/her] face” and was on alert for it bleeding after the resident had scratched it; * 10/15/24: A progress note indicated the resident was on alert for two scratches on his/her face and nose; * 10/17/24: A progress note indicated the resident had an area “on [his/her] face [on] the right side that is open and raised and a second one on [his/her] nose that is not yet opened” and a third one was appearing on the left side of his/her face. Noted that the resident’s doctor was faxed; * 10/18/24: A progress note indicated the “scratch on cheek was open and leaking red colored bodily fluid.” Noted that the “MT attempted to cover open wound, but adhesive would not adhere to skin”; * 10/21/24: Staff documented in a progress note, the resident "was in bed with another resident"; * 10/23/24: Staff documented in a progress note, the resident was on alert for behavior changes. “Resident was aggressive at activities”; * 10/24/24: A progress note indicated the resident was bothering another resident, pulling on the other resident’s jacket, and was aggressive towards the other resident; * 10/25/24: Staff documented in a progress note, the resident’s “toenails are yellow and thick and seemed to be tender to the touch”; * 11/11/24: A progress note indicated the resident had a fall with injury to his/her right shoulder; * 11/19/24: A progress note indicated the resident was going to be sent to urgent care regarding his/her wound on his/her face; * 11/30/24: Staff documented in a progress note, “resident noted to have blood on [his/her] face and clothing, dry blood, on [his/her] face growth to right of face was bleeding”; * 12/04/24: A progress note indicated the resident was admitted to hospice due his/her diagnosis of advance squamous cell carcinoma; and * 01/17/25: A progress note indicated the hospice Certified Nursing Assistant noted the resident’s left leg and ankle was visibly swollen. There was no documented evidence the facility had evaluated the resident, determined actions or interventions specific to each change of condition, communicated the determined actions or interventions to staff, and/or monitored any of the above documented changes of condition to resolution. During an interview on 01/28/25 at 11:15 am, Staff 1 (ED) confirmed there was no additional documentation of skin monitoring by the nurse. On 01/30/25, the need to ensure changes of condition were evaluated to determine what actions or interventions were needed, actions or interventions were communicated to staff on each shift, and conditions were monitored with progress noted at least weekly through resolution was discussed with Staff 1 and Staff 2 (Regional Director of Operations). They acknowledged the findings. 7. Resident 8 was admitted to the facility in 09/2023 with diagnoses including dementia and type II diabetes. The resident's 04/18/24 service plan, temporary service plans and progress notes dated 11/02/24 through 01/27/25 were reviewed and identified the following: * 11/02/24: A progress note indicated the resident was on alert “for sore in mouth on right side”; * 11/3/24: A progress note indicated the resident had started a new medication; * 11/03/24: Staff documented in a progress note the resident had a non-injury fall; * 12/16/24: Staff documented the resident was out of his/her metoprolol (for high blood pressure) medication; * 12/20/24: Staff documented the resident was involved in a resident-to-resident physical altercation; * 12/27/24: Staff documented in a progress note the resident missed his/her dose of olanzapine (for psychiatric disorders); * 01/09/25: A progress note indicated the resident had an injury fall with shoulder pain; * 01/21/25: Staff documented the resident was out of his/her Ozempic (for lowering blood sugar) medication; * 01/22/25: A progress note indicated the resident was on alert protocol for potential flu; and * 01/24/25: Staff documented the resident missed his/her dose of Jardiance (for lowering blood sugar). There was no documented evidence the facility determined what resident-specific actions or interventions were needed for these changes of condition, that determined actions or interventions were communicated to staff, and/or that progress was documented weekly until the condition resolved. On 01/30/25, the need to ensure resident-specific actions or interventions were determined and documented for changes of condition, communicated to staff, and progress monitored and documented at least weekly through resolution was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings. 8. Resident 5 was admitted to the facility in 03/2019 with diagnoses including dementia. The resident's 10/31/24 service plan, progress notes, interim service plans, and incident reports, dated 10/28/24 through 01/28/25, were reviewed. The following short-term changes of condition lacked documented actions or interventions for the changes of condition, communicated to staff on each shift, and/or the change monitored through resolution: * 12/02/24: Covid exposure; * 12/31/24: Fall with head strike; * 01/09/25: Diet change to mechanical soft; * 01/11/25: Fever; and * 01/21/25: Discolored areas to both wrists. The need to ensure changes of condition had actions/interventions determined, communicated to staff on all shifts, and were monitored through resolution was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 01/29/25. They acknowledged the findings. 9. Resident 9 was admitted to the facility in 09/2023 with diagnoses including Alzheimer’s disease and osteoarthritis. The resident's 10/21/24 service plan and progress notes, interim service plans, and incident reports dated 10/28/24 through 01/28/25 were reviewed. The following short-term changes of condition lacked documented evidence actions/interventions were determined, with instructions provided to staff on all shifts, and monitoring of progress noted weekly through resolution: * 11/24/24: Non-injury fall; * 11/25/24: Unwitnessed fall; * 12/02/24: Covid exposure; * 12/25/24: Increased confusion, increase in ADL assist needed; * 01/15/25: Bruising to the left hand and arm; and * 01/24/25: Fall in bathroom. The need to ensure changes of condition had actions/interventions determined, with instructions provided to staff on all shifts, and monitored through resolution was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 01/29/25. They acknowledged the findings.

All falls whether witnessed or unwitnessed will be investigated within 24 hours by the ED or designee and appropriate interventions placed on a TSP and on the service plan and reviewed with care staff. The ED/Designee will monitor the EHR at least 4 days/week for incidents and progress notes. The ED or designee is responsible to complete an investigation on every incident within 24-48 hours, and document on the QAPI. The ED or designee will put into place a TSP for each incident. The HSD or designeee will be notified and will review the TSP, add the interventions to the care plan, and monitor effectiveness of the interventions. The ED or designee will self report to APS as required any report of potential abuse/neglect. The ED or designee is responsible to notify the RN Delegate of any resident with 2 or more falls. Clinical Team Supporting Community has completed the "Role of the Nurse"course, HSD will complete course upon return from Medical Leave. The HSD/Designee will clearly document resolution of each COC in MAR. This review will be completed daily in Clinical Huddle. Regional Director of Health Services (RDHS) to audit weekly x 4 weeks, bi-weekly x 4 weeks, and then will spot check.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by:

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by: Based on interview, and record review, it was determined the facility failed to ensure non-pharmacological interventions were attempted and documented as unsuccessful prior to PRN psychotropic medication being administered for 1 of 2 sampled residents (# 3) who were prescribed as needed psychotropic medications. Findings include, but are not limited to: Resident 3 was admitted to the facility in 11/2024 with diagnoses including Alzheimer’s disease and dementia with psychosis. The resident's 12/01/24 through 01/27/25 MARs and physician’s orders were reviewed. Staff were interviewed and the following was identified: Resident 3 had a physician’s order for PRN quetiapine (for hallucinations, agitation, and dementia with behaviors). The resident received the PRN medication four times between 12/01/24 and 01/27/25. On 01/29/25 at 9:35 am, Staff 1 (ED) was requested to check the computer medication system for direction relating to non-drug interventions to try with Resident 3 prior to administering the PRN psychotropic. Staff 1 confirmed there were no interventions listed for staff to try prior to administration in 01/2025’s MAR and staff failed to document non-drug interventions tried and failed prior to giving the PRN to the resident. Although there were non-drug interventions listed to try prior to administrating the PRN on the 12/2024 MAR, there was no documented evidence staff attempted non-drug interventions prior to the administration of the medication. The need to ensure non-pharmacological interventions were documented as attempted and failed prior to the administration of PRN psychotropics was discussed with Staff 1 on 01/30/25 at 12:33 pm. She acknowledged the findings.

ED(Executive Director)/HSD(Health Services Director)/Designee will reeducate all med techs/staff on using non-pharmcological interventions and documenting the use of all non-pharmcological interventions prior to administration of psychotropics. Resident #3 had interventions in place on the MAR, the medication techs were identified and re-educated on documentation requirements by the Health Services Director on 2/21/2025. HSD/Designee will audit all PRN psychotropic medications ordered to ensure accuracy, and that each prn psychotropic has listed resident specific non-pharmacological interventions that staff are to attempt prior to the administration The Health Services Director/Executive Director/Designee will audit PRN psychotropic medication administration during clinical huddle to verify that non-pharmacological interventions are attempted and documented. The ED/HSD/Designee will spot check at least 3 x's/week x 4 weeks and then and then monthly at the Continuous Quality Improvement meeting.

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by:

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to have a sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident, including sufficient staff to meet the fire safety evacuation standards. Findings include, but are not limited to: The facility was licensed as a Memory Care with a capacity of 66 beds. a. On 01/27/25 during the entrance conference, survey requested a facility staffing policy or a tool to determine number of caregiving staff needed to provide scheduled and unscheduled residents' care needs. The facility acuity-based staffing tool (ABST) for all residents was reviewed during the survey in addition to the facility’s staffing plan. During the acuity interview on 01/27/25 and subsequent resident record reviews, the following care needs were identified: * The facility had a census of 43 residents that resided in three cottages; * Nine residents were identified as requiring two-person transfers or assistance with care; and * Two cottages were locked units and the residents who resided in them (18 residents living in Cottage A and 10 residents living in Cottage B) required the minimum of a one-person assistance for emergency evacuations. The facility ABST was not accurately being used to determine the correct staffing minutes in all cottages relating to the residents who required two staff members for transfers or care. b. The facility's staffing plan, posted during the survey, showed the following: * Cottage A - Day shift: 2 Caregivers and 1 Med Tech; - Swing shift: 2 Caregivers and 1 Med Tech; and - NOC [Night] shift: 1 Caregiver and 1 Med Tech. * Cottage B - Day shift: 2 Caregivers and 0.5 Med Tech; - Swing shift: 2 Caregivers and 0.5 Med Tech; and - NOC shift: 1 Caregiver and 0.5 Med Tech. * Cottage C - Day shift: 2 Caregivers and 0.5 Med Tech; - Swing shift: 2 Caregivers and 0.5 Med Tech; and - NOC shift: 1 Caregiver and 0.5 Med Tech. The facilities schedule did not include a minimum of two care staff present on night shift in cottages B and C, both that had residents requiring two-person assist with transfers and/or care. The facility's failure to ensure staff adequate in number to meet the scheduled and unscheduled needs of the residents was shared with Staff 1 (ED) on 01/30/25 at 12:33 pm. She acknowledged the findings.

HSD/ED/Designee will update the ABST tool prior to a resident moving in, with quarterly service plan updates and with any change of condition. ED/Designee will audit 10% of resident evaluations/service plans per month to ensure accuracy of services provided and time of care provided. ED/Designee will ensure that staffing meets or exceeds the ABST tool to meet resident's scheduled and unscheduled needs

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by:

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to have accurate care minutes included on the acuity-based staffing tool (ABST) for 4 of 5 sampled residents (#s 1, 2, 3, and 4) and two unsampled residents. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 12/2022 with diagnoses including cerebral palsy. Observations of the resident, interviews with staff, and review of the resident’s records revealed Resident 2's ABST minutes and/or frequencies were not reflective in the following areas: * Supervising, cueing, or supporting while eating; and * Transfers. On 01/30/25, the need to ensure ABST entries were reflective of resident care needs was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings. 2. Resident 4 was admitted to the facility in 09/2024 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident’s records revealed Resident 4's ABST minutes and/or frequencies were not reflective in the following areas: * Transfers; * Dressing and undressing; and * Toileting, bowel, and bladder management. On 01/30/25, the need to ensure ABST entries were reflective of resident care needs was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings. 3. Resident 3 was admitted to the facility in 11/2024 with diagnoses including Alzheimer’s disease and dementia with psychosis. Observations of the resident, interviews with staff, and review of the resident records revealed Resident 3's ABST minutes and/or frequencies were not reflective in the following areas: * Monitoring behavioral conditions or symptoms; * Ensuring non-drug interventions for behaviors; * Cueing or redirecting due to cognitive impairment or dementia; and * Resident-specific housekeeping or laundry services performed by care staff. The need to ensure ABST entries were reflective of resident care needs was discussed with Staff 1 (ED) on 01/30/25 at 12:33 pm. She acknowledged the findings. 4. Resident 1 was admitted to the facility in 05/2024 with diagnoses including vascular dementia and a fractured left tibia. Observations of the resident, interviews with staff, and review of the resident’s records revealed Resident 1's ABST minutes and/or frequencies were not reflective in the following areas: * Monitoring behavioral conditions or symptoms; * Ensuring non-drug interventions for behaviors; * Cueing or redirecting due to cognitive impairment or dementia; * Providing treatments (e.g. skin care, wound care, antibiotic treatment); * Supervising, cueing, or supporting while eating; * Repositioning in bed or chair; and * Transferring in or out of bed or chair. The need to ensure ABST entries were reflective of resident care needs was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 01/30/25. They acknowledged the findings. 5. During the acuity interview on 01/27/2025, staff identified two unsampled residents needing two staff members for transferring. On 01/27/25 at 3:08 pm, the unsampled residents were reviewed in the facility’s ABST and reflected zero minutes needed for transferring. The need to ensure ABST entries were reflective of resident care needs was discussed with Staff 1 (ED) on 01/30/25 at 12:33 pm. She acknowledged the findings.

Health Services Director/Executive Director/Designee will update the ABST tool prior to a resident moving in, with quarterly service plan updates and with any change of condition. Residents 1,2,3, and 4 ABST were updated on 2/6/2024 by the Regional Director of Health Services utilizing staff input, and resident observation. ED educated the Resident Care Coordinator on 2/19/2025 on how time is to be entered into the ABST based on the evaluation, actual time of resident care. ED/Designee will audit 10% of residents each week x 4 weeks utilizing evaluations/service plans, timing resident care, and staff interviews to ensure accuracy of services provided and time of care provided and update the ABST as required. ED/Designee will ensure that accurate care minutes are included on the ABST.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by:

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 update the acuity-based staffing tool (ABST) before a resident moved into the facility for 2 of 2 sampled residents (#s 3 and 6) and for nine unsampled residents, and no less than quarterly for 1 of 1 unsampled resident. Findings include, but are not limited to: Review of the ABST on 01/27/25 revealed the following: * Resident 3 admitted to the facility in 11/2024. The ABST reflected care minutes were entered three days after the resident moved in; * Resident 6 admitted to the facility in 11/2024. The ABST reflected care minutes were entered two days after the resident moved in; * The ABST reflected that nine unsampled residents had their care minutes entered between one and twelve days after admitting to the facility; and * One unsampled resident’s ABST had not been updated since 09/2024. The need to ensure residents' ABST was updated prior to move-in and at least quarterly was reviewed with Staff 1 (ED) on 01/30/25 at 12:33 pm. She acknowledged the findings.

ED will educate Resident Care Coordinator (RCC)/HSD on ABST update requirements to include: prior to move in, quarterly service plans and with any change of condition. Regional Director of Health Services completed an audit of the ABST tool on 2/6/2025 and on 2/12/2025 on all residents to ensure that all residents had been updated quarterly and with change of conditions, any time that was not reflective of needs was updated. ED/HSD and/or Designee will audit ABST prior to any new resident move in to ensure that care time is reflected accurately. Health Services Director/Executive Director/Designee will update the ABST tool prior to a resident moving in, with quarterly service plan updates and with any change of condition. ED educated the Resident Care Coordinator on 2/19/2025 on how time is to be entered into the ABST based on the evaluation, actual time of resident care. ED/Designee will audit 10% of residents each week x 4 weeks utilizing evaluations/service plans, timing resident care, and staff interviews to ensure accuracy of services provided and time of care provided and update the ABST as required. ED/Designee will audit the ABST one time per month to ensure ABST is updated prior to move in, at least quarterly and with change of condition and report to the Continuous Quality Improvement meeting.

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:

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to Oregon Fire Code and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to: Six months of fire drill records were reviewed on 01/28/25 and revealed the following: a. Fire drills lacked documentation of one or more of the following components: * The escape route used; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Evacuation time-period needed; and * Number of occupants evacuated. In an interview on 01/28/25, Staff 1 (ED) and Staff 2 (Regional Director of Operations) acknowledged the documentation lacked one or more of the required components. b. The facility failed to provide fire and life safety instruction to staff on alternate months. In an interview on 01/28/25, Staff 1 confirmed staff were not provided fire and life safety instruction on alternating months. The need to ensure fire drills were conducted according to Oregon Fire Code with all required components documented and fire and life safety instruction to staff was provided on alternating months was discussed with Staff 1, and Staff 2 on 10/28/25. They acknowledged these findings.

Maintenance Director (MTD) will be educated by Director of Facilities on expectations of fire drills and requirement of alternating monthly fire and life safety trainings. The updated fire drill report was placed in use on 1/29/2025 and contains all required information: escape route used; problems encountered and comments relating to residents who resisted/failed to participate; evacuation time needed and number of occupants evacuated. Fire Drills and monthly all staff meeting education will be tracked utilizing the appropriate forms and uploaded into TELS. Fire drills will be reported through the monthly CQI meeting. * BOM/Designee will track all staff training as completed and report to ED. Executive Director/Designee will audit the fire drill forms monthly to ensure all required information is contained. ED/Designee will monitor through the monthly CQI meeting training topics and fire drills.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by:

OAR 411-054-0200 (8) Heating and Ventilation (8) HEATING AND VENTILATION SYSTEMS. A RCF must have heating and ventilation systems that comply with the building codes in effect at the time of facility construction. (a) TEMPERATURE. For all areas occupied by residents, design temperature for construction must be 75 degrees Fahrenheit. (A) A RCF must provide heating systems capable of maintaining 70 degrees Fahrenheit in resident areas. Required minimum temperatures are no less than 70 degrees Fahrenheit during the day and 60 degrees Fahrenheit during sleeping hours. (B) During times of extreme summer heat, fans must be made available when air conditioning is not provided. (b) EXHAUST SYSTEMS. All toilet and shower rooms must be equipped with a mechanical exhaust fan or central exhaust system that discharges to the outside. (c) FIREPLACES, FURNACES, WOODSTOVES, AND BOILERS. Where used, installation must meet standards of the building codes in effect at the time of construction. The glass and area surrounding the fireplace must not exceed 120 degrees Fahrenheit. (d) WALL HEATERS. Covers, grates, or screens of wall heaters and associated heating elements may not exceed 120 degrees Fahrenheit when they are installed in locations that are subject to incidental contact by people or with combustible material. Effective 01/15/2015, wall heaters are not acceptable in new construction or remodeling. This Rule is not met as evidenced by: Based on observation, and interview, it was determined the facility failed to ensure resident areas maintained a minimum temperature of no less than 70 degrees Fahrenheit during the day. Findings include, but are not limited to: Observations during the survey from 01/27/25 through 01/30/25 revealed temperatures inside Cottage C were consistently below 70 degrees during daytime hours. Temperatures obtained from the common area thermostat included the following: a. Rear corridor thermostat: * 01/27/25 at 12:15 pm, 1:30 pm, and 2:30 pm, thermostat was at 69 degrees; * 01/28/25 at 10:00 am, thermostat was at 68 degrees; and * 01/28/25 at 12:27 pm, thermostat was at 69 degrees. b. Front corridor thermostat: * 01/28/24 at 10:00 am, thermostat was at 66 degrees; and * 01/28/25 at 12:27 pm, thermostat was at 67 degrees. On 01/28/25, the need to ensure resident areas were maintained at a minimum of no less than 70 degrees during the day was discussed with Staff 1 (ED). She acknowledged the findings and reported the facility would get corridor thermostats adjusted.

Maintenance Director (MTD) to track internal temperatures weekly utilizing approriate forms and upload into TELS. ED to check temperatures in common areas daily x 4 weeks during rounds and notify MTD of concerns, and then spot check at least twice per month.

OAR 411-054-0200 (8) Heating and Ventilation (8) HEATING AND VENTILATION SYSTEMS. A RCF must have heating and ventilation systems that comply with the building codes in effect at the time of facility construction. (a) TEMPERATURE. For all areas occupied by residents, design temperature for construction must be 75 degrees Fahrenheit. (A) A RCF must provide heating systems capable of maintaining 70 degrees Fahrenheit in resident areas. Required minimum temperatures are no less than 70 degrees Fahrenheit during the day and 60 degrees Fahrenheit during sleeping hours. (B) During times of extreme summer heat, fans must be made available when air conditioning is not provided. (b) EXHAUST SYSTEMS. All toilet and shower rooms must be equipped with a mechanical exhaust fan or central exhaust system that discharges to the outside. (c) FIREPLACES, FURNACES, WOODSTOVES, AND BOILERS. Where used, installation must meet standards of the building codes in effect at the time of construction. The glass and area surrounding the fireplace must not exceed 120 degrees Fahrenheit. (d) WALL HEATERS. Covers, grates, or screens of wall heaters and associated heating elements may not exceed 120 degrees Fahrenheit when they are installed in locations that are subject to incidental contact by people or with combustible material. Effective 01/15/2015, wall heaters are not acceptable in new construction or remodeling. This Rule is not met as evidenced by:

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide a call system that connected resident units and bathrooms to the care staff center, staff pagers, or a wireless call system. Residents were unable to contact staff to request help when needed, constituting a threat to their health, safety, and welfare. The facility also failed to have a system to notify staff of residents exiting the facility. Findings include, but are not limited to: The facility was made up of three separate cottages. Cottages A and B were secured memory care units, and Cottage C was an unlocked residential care unit. 1. The facility’s call system was connected to an iPad that was stored in the Medication Room. CGs reported that they used to carry iPhones. Both MTs and CGs were supposed to have walkie talkies with them while they were on shift. When a resident called for assistance, the MTs would use the walkie talkie to let CGs know which room, or which resident needed help. Staff confirmed that not everyone had an operable walkie talkie as sometimes they were not properly charged, and other times facility and/or agency staff would take them home. There were no iPhones available for staff use during survey. The following issues with the call system were identified: a. Resident Council Meeting minutes for 01/07/25 were reviewed on 01/28/25 and indicated there was a problem with the call system: * One unsampled resident expressed his/her concerns about how the residents would be able to get the assistance they needed and said, “The system is broken.” * Staff documented that during the Resident Council Meeting on 01/07/25, an unsampled resident pressed his/her wrist pendant to see how long it would take care staff respond. This was at approximately 2:00 pm, which was the beginning of the meeting. At approximately 3:00 pm, when the meeting was coming to a close, a CG came to answer the resident’s pendant. Staff documented that the CG “was informed that the pendant had been activated since the beginning of the meeting and that it was not appropriate to take so long to respond.” The CG responded that the iPhone’s battery “was dead” and that it “was charging”. b. Interviews and observations were conducted during the survey with residents, care staff, and visitors, and the following was reported: * On 01/28/25 at 4:23 pm, Resident 4 knocked on the door where survey was working and asked about getting a haircut. The surveyor asked Resident 4 if it was alright if the resident pressed the necklace pendent to call staff, and observed the resident push the button firmly. By 4:45 pm, no staff came to assist. At approximately 4:50 pm, Staff 5 (RCC) was walking down the hall and the need for scheduling a haircut appointment was discussed. By 5:11 pm, Resident 4 was sitting in the dining room getting ready to eat dinner and confirmed no one had checked on him/her or reset the pendent. * During an interview with Staff 10 (MT), on 01/29/25, it was reported resident rooms had pull cords for assistance. The alerts went to facility iPad and iPhones the caregivers carried with them. Staff 10 reported that without the iPhones staff would not know if a resident had pressed their pendent or used the pull cord. Staff 10 was not sure how many iPhones caregivers had between the three cottages, but believed there were only two iPads, and there was a cottage without an iPad to alert staff if a resident needed assistance. * On 01/29/25 at 3:22 pm, an unsampled resident reported that it “usually” took an hour or more to get assistance after pushing his/her call light, and s/he could tell when it was not the result of calling for assistance as staff “don’t reset [the call light] when they come in.” * Resident 4 reported that the call light system works “sometimes but not all of the time.” * Resident 9 resided in Cottage B had returned to the facility on 01/09/25, after a hospitalization with surgical intervention. Records reviewed revealed that after returning to the facility the resident fell on 01/21/25 and 01/27/25. During an interview with Resident 9 on 01/29/25 about use of the call light, s/he reported using it “sometimes”, and then stated, “no one ever comes, so it’s useless if you ask me.” * There was only one iPad in Cottage A, and “no one knows how to use it for call lights.” * There were no iPads available in Cottage B. “No one carries one in Cottage B.” * On 01/29/25 at 5:45 pm, Staff 11 (CG) reported the call system had not been working for two to three months. The CG reported thinking it was possible that some residents may have tried to pull their call light, and it never got answered so they got up and fell but wasn’t sure. * On 01/28/25 at 03:35 pm, Staff 19 (CG) reported that resident’s roommates had been helping each other with caregiving tasks since nobody came to answer the call lights. * The family of a resident who was dependent on staff for transfers and ADLs had to purchase a handheld bell for the resident, so the resident could ring the bell for assistance. * On 01/29/25 at 3:26 pm, a resident’s family member reported having to run and find staff for their loved one since the call system was broken. c. An audit of call light response times was conducted and revealed the following: * Call light times from 01/12/25 through 01/27/25 were reviewed for Residents 2 and 4, both of whom lived in Cottage C, and revealed 21 occasions when staff response time was greater than 15 minutes. Eight of the 21 occasions were greater than two hours. On 01/28/25 at 12:50 pm, Staff 1 (ED) confirmed she was aware the facility did not have an operable call system and stated she had ordered more iPads. The facility failed to ensure residents had a working call system, which left residents unable to call for assistance when needed and placed the resident’s health, safety, and welfare at risk. On 01/29/25 at 4:00 pm the facility was asked to complete and provide an immediate plan of correction. The plan of correction was received and accepted at 5:29 pm. The facilities plan included having one designated staff in each of the three cottages at all times to provide resident checks every 30 minutes or one hour, depending on the needs of the residents. This was to continue until the arrival and implementation of the iPads, as well as staff education relating to the new call system response protocol. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation. The need to have an operational call system that connected residents to the care staff or staff pagers was discussed with Staff 1 and Staff 2 (Regional Director of Operations) on 01/29/25. They acknowledged the findings. 2. 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: Observations on 01/28/25 revealed exit doors in Cottages A and B did not have an operational alarm or other acceptable system to alert staff when residents exited the building. The alarms on entrance doors and the two doors leading to the secured courtyards of both A and B cottages were not alerting staff when the doors were opened. The need to ensure exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the building was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 01/28/25. They acknowledged the findings.

iPad/iPhone arrival date 01/31, walkie talkie arrival date 02/04, all staff training on appropriate usage of equipment completed 02/10, ongoing as needed. 1. Additional Documentation to Ensure Regular Safety Checks on Resident: o One person in each building will be designated to just know the whereabouts of each resident and document it. o Tracking of these checks will be completed on a resident roster. Ascot Park staff (not agency) will sign off stating what the resident is doing either every 30 minutes or hour depending on the unique needs of residents. This will continue until the arrival and implementation of iPads. 2. Designation of Care Staff Center Personnel: o One (additionally added) Ascot Park staff member per shift will be designated as the Care Staff Center contact. o This individual will be responsible for receiving and monitoring call system notifications. 3. Assignment of Call Light Response Personnel: o Each building will have one designated staff member assigned to a walkie-talkie to receive call system notifications from the Care Staff Center designee. o This staff member will be responsible for responding to call lights. If they are providing care, they will request assistance the rounder or the Med Tech. 4. Training and Implementation: o All staff will be provided an in-service on the new call light response protocol upon arrival and implementation of the iPads. o Training will include proper use of the call system, walkie-talkie assignments, and the process for ensuring timely responses. 5. Assignment and Accountability: o The Executive Director (ED) or designee will be responsible for assigning a Care Staff Center designee and designated call light response personnel for each building per shift. o Walkie-talkies will be signed out by the Care Staff Center designee to the designated call light response staff at the beginning of each shift. o At the end of each shift, the walkie-talkies will be returned and signed back in by the Care Staff Center designee. o Community currently has 6 working Walkie Talkies. We have ordered 10 additional arriving ETA 2/1. Upon arrival of the walkie talkies, there will be enough for AM& PM shifts. We will alternate though charging of equipment. 6. Monitoring and Compliance: o The ED, HSD or designee will conduct random audits to ensure compliance with the new protocol. o Any issues with response times or staff compliance will be addressed through additional training or corrective action as needed. o 7. Installation of Sounded Door Alarms for Cottage A & B o Completion Date (upon arrival of equipment), no later than February 2, 2025. o Until Completion, Action Item #1 will remain in place. 8. Call Light System Audits to Ensure System is Running Effectively o Weekly Audits through 3/2025 o Bi-Weekly Audits through 4/2025 o Monthly Audits Moving Forward Responsible Party: Executive Director, Health Services Director (HSD) or Designee

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by:

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure privacy and dignity related to no locks on bathroom doors for residents who had shared bathrooms. Findings include, but are not limited to: On 01/28/25, observations of the shared bathrooms with Staff 1 (ED) and Staff 2 (Regional Director of Operations) revealed the doors to residents’ shared bathrooms did not have locking mechanisms to ensure privacy and dignity. On 01/30/25, the need to ensure shared bathroom doors had locks were reviewed with Staff 1. She acknowledged the findings.

Director of Facilities & MTD to ensure each unit has a locking door on the bathroom to ensure privacy and dignity, to be completed on or before 3/15/2025.

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by:

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. Findings include, but are not limited to: Refer to: C 150, C 154, C 231, C 242, C 360, C 363, C 420, C 540, and C 555.

Refer to C150, C154, C231, C242, C360, C363, C420, C540, 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:

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. Findings include, but are not limited to: Refer to C 252, C 260, C 270, C 330, and C 362.

Refer to C252, C260, C270, C330, C362.

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:

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure a daily meal program based on resident's preferences and needs that was individualized and documented in the resident's service plan for 2 of 3 sampled residents (#s 1 and 8) whose service plans were reviewed. Findings include, but are not limited to: Resident 1 and 8’s current service plans were reviewed during survey. Each service plan lacked information and/or staff instructions related to the individualized nutrition and hydration status, preferences, and needs of the resident. The need to develop a daily meal program based on resident's preferences and needs that was individualized and documented in the resident's service plan was discussed with Staff 1 (ED) on 01/30/25. She acknowledged the findings.

Resident # 1 and Resident #8 nutrition and hydration plans were updated by the Regional Director of Health Services(RDHS) on 2/6/2025 to include preferences, limitations, abilities. The RDHS/ED will complete an audit of all evaluations to ensure the nutrition/hydration plans are reflective of preferences, limitations, abilities; resident/family/staff interviews will be utilized where needed. The ED/Designee will audit nutrition and hydration plans upon move in, and with quarterly updates.

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills. This Rule is not met as evidenced by:

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident 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 interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident, based on an activity evaluation, for 2 of 4 sampled residents (#s 1 and 8) whose records were reviewed. Findings include, but are not limited to: Resident service plans and activity evaluations were reviewed. There was no documented evidence the facility had fully evaluated and developed individualized plans based on the residents': * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Identification of activities for behavioral interventions, if necessary. On 01/30/25, the need to ensure residents had individualized activity plans developed based on their activity evaluations was discussed with Staff 1 (ED). She acknowledged the findings.

Life Stories will be obtained for all residents by the Resident Experience Director (RED)/Executive Director/Designee. RED/ED will give a list of resident specific likes/dislikes for activities to the ED/HSD to update service plans. Service plans will be updated by the ED/HSD/Designee to reflect activity/engagement plans. The ED/HSD/Designee will provide ongoing audit of service plans for activity plans with move in, change in condition, and at least quarterly. Results of audits will be reported to the Continuous Quality Improvement team at next scheduled meeting

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident 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:

OAR 411-057-0160(e) Behavior (e) Behavioral symptoms which negatively impact the resident and others in the community must be evaluated and included on the service or care plan. The memory care community must initiate and coordinate outside consultation or acute care when indicated. This Rule is not met as evidenced by: Based on interview, and record review, it was determined the facility failed to ensure behavioral symptoms that negatively impacted the resident or others in the community were included on the service plan for 3 of 3 sampled residents (#s 1, 3, and 8) with documented behaviors. Findings include, but are not limited to: During the acuity interview on 01/27/25, Resident’s 1, 3, and 8 were identified as being involved in resident-to-resident altercations and/or sexual behaviors. The residents’ facility records were reviewed, which included Resident 1, 3, and 8’s service plans that were available to staff, and Observation notes. The Observation notes contained documented evidence which confirmed the behaviors identified during the acuity interview. The three identified residents’ service plan did not address the behaviors and lacked individualized interventions to assist staff in minimizing the negative impact of the behaviors. On 01/30/25, the need to include residents’ behavioral symptoms on the service plan was discussed with Staff 1 (ED). She acknowledged the findings.

Resident #1, Resident #3 and Resident #8 behavioral plans were updated on 2/6/2025 by the LPN to reflect person centered interventions for behaviors. The ED/Designee will obtain behavioral health referrals for Resident #1 and Resident #8. RDHS/LPN/Designee will audit all service plans for the residents in Memory Care and update Behavioral plans, ensuring person centered interventions are in place. Interventions will be communicated to the care team via Temporary Service Plans (TSPs). ED/HSD/Designee will audit TSPs, progress notes and interventions in the clinical huddle.

OAR 411-057-0160(e) Behavior (e) Behavioral symptoms which negatively impact the resident and others in the community must be evaluated and included on the service or care plan. The memory care community must initiate and coordinate outside consultation or acute care when indicated. This Rule is not met as evidenced by:

OAR 411-057-0170(9) Resident Rooms (9) RESIDENT ROOMS. (a) Residents may not be locked out of or inside of their rooms at any time. (b) Residents must be encouraged to decorate and furnish their rooms with personal items and furnishings based on the resident's needs, preferences, and appropriateness. (c) The memory care community must individually identify residents' rooms to assist residents in recognizing their room. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to individually identify residents' rooms to assist residents in recognizing their room. Findings include, but are not limited to: The MCC was toured on 01/29/25 and 01/30/25. * Resident rooms in Cottage A - 101, 103, 106 and 108; and * Resident rooms in Cottage B - 103, 104, 105, 107 and 112 lacked any individualized identification to assist residents in recognizing their room. The need to ensure each resident room was identified for the resident was reviewed with Staff 1 (ED) on 01/30/25 at 11:45 am. She acknowledged the findings.

ED, RED and Designee will contact families for current residents to collect resident pictures on or before 3/15/2025. RED & MTD will ensure all resident rooms have personalized pictures posted outside of their units to identify their living space on or before 3/20/2025. ED, RED and Community Resource Director (CRD) will ensure a new resident picture is collected upon move in. The ED/MTD will audit room personalization monthly on the internal CBC walkthrough and report to the Continuous Quality Improvement Meeting monthly.

OAR 411-057-0170(9) Resident Rooms (9) RESIDENT ROOMS. (a) Residents may not be locked out of or inside of their rooms at any time. (b) Residents must be encouraged to decorate and furnish their rooms with personal items and furnishings based on the resident's needs, preferences, and appropriateness. (c) The memory care community must individually identify residents' rooms to assist residents in recognizing their room. This Rule is not met as evidenced by: