OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to immediately notify the local Senior and People with Disabilities (SPD) office when an incident of abuse, or suspected abuse, occurred, failed to report physical injuries of unknown cause to the local SPD office as suspected abuse, unless an immediate facility investigation reasonably concluded and documented the physical injury was not the result of abuse, and failed to promptly investigate incidents for 3 of 3 sampled residents (#s 1, 2 and 6). Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 08/2024 with diagnoses including dementia and Parkinson’s disease. The resident's 01/15/25 through 04/15/25 progress notes, temporary service plans, outside provider notes, incident reports and incident investigations were reviewed, and interviews with staff were conducted. The following incidents were identified: *04/01/25: Resident was found on the floor with an injury to the right side of his/her head, left knee, and right upper arm. *04/10/25: At approximately 4:00 am the resident was found on the floor of his/her bedroom with a laceration to his/her right elbow. *04/10/25: A visiting hospice provider documented bandaging a right hip wound. There was no previous documentation as to the cause of the wound. *04/10/25: At approximately 10:40 pm the resident was found on the floor of his/her room with a laceration to his/her head. *04/14/25: The resident was found on the floor of his/her bedroom and had a left elbow wound which required treatment. There was no documented evidence the incidents of abuse, or suspected abuse, were immediately reported to the local SPD office or that the injuries of unknown cause were immediately investigated and abuse ruled out. The survey team requested that the above incidents be reported to the local SPD office immediately, and confirmation of reporting was provided by 5:48 pm on 04/17/25. The need to ensure abuse or suspected abuse was immediately reported to the local SPD office, and all injuries of unknown cause were immediately reported to the local SPD office, unless an immediate investigation reasonably concluded that the injury was not the result of abuse, was reviewed with Staff 1 (ED) and Staff 3 (RCC) on 04/17/25 at 12:55 pm. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 10/2022 with diagnoses including severe vascular dementia with mood disturbance, dissociative personality disorder, and history of traumatic brain injury. The resident’s current service plan, progress notes from 01/15/25 through 04/15/25, temporary service plans, and incidents were reviewed. Interviews with staff were conducted. The following was identified: * Resident 1 had five resident-to-resident altercations on: - 02/08/25 at 2:00 pm and another at 4:00 pm; - 02/12/25; and - 03/01/25 at 7:13 pm and another at 7:30 pm. * All of these resident-to-resident altercations were reported to the local Seniors & People with Disabilities (SPD) office two days after the events. * Investigations for the five altercations were conducted between two and five days following the incidents. In interview on 04/17/25 at 1:50 pm, Staff 1 (ED) reported she did sometimes call in reports of resident-to-resident altercations within 24 hours of the incident, especially if they occurred on a weekend, but didn’t email SPD until the next business day. The need to report incidents of abuse or suspected abuse to SPD immediately and to investigate incidents promptly was discussed with Staff 1 and Staff 3 (RCC) on 04/17/25. They acknowledged the findings. 3. Resident 2 was admitted to the facility in 12/2021 with diagnoses including dementia. During the survey the resident was observed to be a one-person full assist for all mobility and ADL tasks. Interviews with staff, and review of the resident's 01/09/25 service plan and available temporary service plans, progress notes, and incident investigations from 01/19/25 through 04/15/25, were completed. The following was identified: * 1/19/25 - Bruise to left wrist found, measured approximately 2 inches long by 1 inch wide. During an interview with Staff 2 (RN) on 04/16/25 at 11:49 am. she reported there was no incident investigation completed to rule out abuse for the injury of unknown cause, and the incident had not been reported to the local SPD office. The need to ensure all injuries of unknown cause were immediately reported to the local SPD office unless an immediate investigation reasonably concluded that the injury was not the result of abuse was discussed with Staff 1 (ED) and Staff 3 (RCC) on 04/17/25. They acknowledged the findings. The facility was instructed to report the injury of unknown cause to the local SPD office on 04/16/25. Documentation of reporting requested was received from the facility by 4:00 pm.

1. All incidents listed in the SOD regarding residents #1, 2 & 6 were followed up on and reported to the local APS office upon education from the survey team. 2. When an incident is reported to APS, whether it is via phone call or email, the person doing the reporting will make a progress note in the resident chart to show what action has been taken. 3. ED and clinical leadership will review IR’s and incidents that need to be reported daily. 4. ED/LN/RCC’s

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 411-054-0034 (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 observation, interview, and record review, it was determined the facility failed to ensure the evaluation described the resident's physical health status, mental status, and the environmental factors that helped the individual function at their optimal level, including data relevant to the residents' needs and current condition, and that move-in evaluations included all required elements, for 5 of 7 residents (#1, 4, 5, 6, and 7) whose evaluations were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 01/2023 with diagnoses including dementia and congestive heart failure. The resident’s most recent evaluation, dated 04/01/25, was reviewed. The quarterly evaluation was not relevant to the needs and current condition of the resident in the following areas: * Customary routines, dining location; * Recent medical concerns and hospitalizations; * Location of side rails; * Safety checks; * Strategies to reduce pressure on coccyx; and * Repetitive behaviors including skin picking. The need to ensure the evaluation described the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level, including data relevant to the residents' needs and current condition, was reviewed with Staff 1 (ED) and Staff 3 (RCC) on 04/17/25 at 12:55 pm. They acknowledged the findings. 2. Resident 6 was admitted to the facility in 08/2024 with diagnoses including dementia and Parkinson’s disease. The resident’s most recent evaluation, dated 03/14/25, was reviewed. The quarterly evaluation was not relevant to the needs and current condition of the resident in the following areas: * Customary routines including dining; * Assistance required to attend meals, walk, and get in and out of bed; * Recent medical concerns and hospitalizations; * Chewing and swallowing difficulties; * Assistance required with eating; * Fall interventions; * Wandering outside; and * Behaviors including aggression toward family and staff. The need to ensure the evaluation described the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level, including data relevant to the residents' needs and current condition, was reviewed with Staff 1 (ED) and Staff 3 (RCC) on 04/17/25 at 12:55 pm. They acknowledged the findings. 3. Resident 7 moved into the facility in 03/2025 with a diagnosis of dementia. The resident’s move-in evaluation dated 03/09/25 was reviewed and failed to address the following required elements: * Interests, hobbies, social, and leisure activities; * Mental health issues, including presence of depression, thought disorders or behavioral or mood problems; history of treatment, and effective non-drug interventions; * Personality, including how the person copes with change or challenging situations; * Activities of daily living, including use of wheelchair; * Pain, including non-pharmaceutical interventions and how a person expresses pain or discomfort; and * Nutrition habits and fluid preferences. The need to ensure move-in evaluations addressed all required elements was discussed with Staff 1 (ED) and Staff 3 (RCC) on 04/17/25. They acknowledged the findings. 4. Resident 4 was admitted to the facility in 07/2024 with diagnoses including vascular dementia and diabetes. Review of the resident's quarterly evaluation, dated 04/08/25, progress notes, observations of the resident, and staff interviews were conducted, which revealed the most recent evaluation did not address all required elements to reflect the current needs and condition of the resident, to include the following: * Diet; * Skin condition; and * Treatments. The need to complete quarterly evaluations that addressed all required elements to reflect the needs and current condition of the resident was discussed with Staff 2 (RN) on 04/16/25, and Staff 1 (ED) and Staff 3 (RCC) on 04/17/25. They acknowledged the findings. 5. Resident 1 was admitted to the facility in 10/2022 with diagnoses including severe vascular dementia with mood disturbance, dissociative personality disorder, and history of traumatic brain injury. Resident 1’s quarterly evaluation, dated 03/25/25, and his/her current service plan were reviewed, and staff were interviewed. The evaluation was not reflective of the resident’s current status and care needs in the following areas: * Smoking status; and * Shower assistance required. On 04/17/25, the need for evaluations to reflect the needs and current condition of residents was discussed with Staff 1 (ED) and Staff 3 (RCC). They acknowledged the findings.

1. Residents #1,4,5,6 & 7 all had discrepancies from the evaluation to service plan to reality of care being given. RN updated evaluations to reflect the current resident status and needs. This flowed through to corrections on the service plan. 2. Assessments will be done thoroughly and will include input from the floor staff as they are the ones who work closest with the residents. After the assessment is completed, the service plan will be updated as well to reflect current needs. 3. Upon admission, 30-days after admission, quarterly and as needed with change of condition. 4. ED/LN/RCC’s

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 reflected residents’ needs as identified in their evaluations and/or lacked clear directions to staff for 5 of 7 residents (#s 1, 2, 5, 6, and 7) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 10/2022 with diagnoses including severe vascular dementia with mood disturbance, dissociative personality disorder, and history of traumatic brain injury. The resident’s current service plan was reviewed, and staff were interviewed. The service plan was not reflective of the resident’s current needs in the following areas: * Smoking status; and * Shower assistance needed. The need for service plans to accurately reflect the residents’ needs was discussed with Staff 1 (ED) and Staff 3 (RCC) on 04/17/25. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 01/2023 with diagnoses including dementia and congestive heart failure. The resident's current service plan available to staff, dated 04/01/25, and 01/15/25 through 04/15/25 progress notes and temporary service plans were reviewed, interviews with staff were conducted, and observations of the resident were completed. The resident's service plan was not reflective of current needs and/or did not provide clear direction to staff in the following areas: * Location of side rails; * Frequency of safety checks; * Assist with evening toileting; * Pain and non-pharmacological interventions; * Oxygen use; * Hospice responsibilities; * Signs and symptoms to monitor for related to diagnoses including congestive heart failure and hyperglycemia; * Hearing; and * Repetitive skin picking. The need to ensure service plans were reflective and provided clear direction to staff was reviewed with Staff 1 (ED) and Staff 3 (RCC) on 04/17/25 at 12:55 pm. They acknowledged the findings. 3. Resident 6 was admitted to the facility in 08/2024 with diagnoses including dementia and Parkinson’s disease. The resident's current service plan available to staff, dated 03/14/25, and 01/15/25 through 04/15/25 progress notes and temporary service plans were reviewed, interviews with staff were conducted, and observations of the resident were completed. The resident's service plan was not reflective of current needs and/or did not provide clear direction to staff in the following areas: * Assistance provided by staff, hospice, and private caregiver; * Ability to use call light, swallow medications whole, ambulate, and transfer; * Assistance required with evacuation; * Assistance required with toileting; * Fall risk and fall interventions; * Pain; * Skin concerns; and * Behaviors including aggression toward family and staff. The need to ensure service plans were reflective and provided clear direction to staff was reviewed with Staff 1 (ED) and Staff 3 (RCC) on 04/17/25 at 12:55 pm. They acknowledged the findings. 4. Resident 2 was admitted to the facility in 12/2021 with diagnoses including dementia. Observations of the resident, interviews with staff and review of the service plan, dated 01/09/25, showed the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas: * Ambulation ability; * Pressure reducing cushion in recliner; * Air mattress on bed; * Back pain, non-drug interventions; * Straw in drinks; * Specific instructions for positioning using pillows in recliner and bed; and * Transfers. The need to ensure resident service plans were reflective of current care needs, were consistently implemented and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (RCC) on 04/17/25. They acknowledged the findings. Staff 3 updated the service plan to address the identified areas on 04/17/25. 5. Resident 7 moved into the facility in 03/2025 with a diagnosis of dementia. The resident's clinical record, including the service plan, dated 03/11/25, progress notes, dated 03/12/25 through 04/15/25, and temporary service plans were reviewed. Resident 7 was observed, and staff were interviewed. 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: * Food and beverage preferences; * Weight loss including interventions to prevent further loss; * Level of assistance with use of wheelchair; * Behaviors and interventions; * Falls and current interventions; and * Level of assistance needed for ADLs, including toileting and incontinent care. 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 3 (RCC) on 04/17/25. They acknowledged the findings.

1. There will be a complete audit of all service plans for the items in the OARS. Regarding residents #1,2,5,6 & 7- service plans will be revised to include the following information: #1- Smoking status and shower assistance needed #5- Location of side rails; Frequency of safety checks; Assist with evening toileting; Pain and non-pharmacological interventions; Oxygen use; Hospice responsibilities; Signs and symptoms to monitor for related to diagnoses including congestive heart failure and hyperglycemia; Hearing; and Repetitive skin picking. #6- Assistance provided by staff, hospice, and private caregiver; Ability to use call light, swallow medications whole, ambulate, and transfer; Assistance required with evacuation; Assistance required with toileting; Fall risk and fall interventions; Pain; Skin concerns; and Behaviors including aggression toward family and staff. #2- Ambulation ability; Pressure reducing cushion in recliner; Air mattress on bed; Back pain, non-drug interventions; Straw in drinks; Specific instructions for positioning using pillows in recliner and bed; and Transfers. #7- Food and beverage preferences; Weight loss including interventions to prevent further loss; Level of assistance with use of wheelchair; Behaviors and interventions; Falls and current interventions; and Level of assistance needed for ADLs, including toileting and incontinent care. 2. An outline of OAR specific details that are required for service plans will be provided to the RCC's for their reference with an emphasis on including all resident specific details that are important for care staff to provide person-centered care. During the 90 day period between service plan updates, we will be requiring the service plan to be revised if there are several updates or a change of condition, rather than just TSP updates. 3. LN will alert RCC's to official changes of condition as they occur. Service plans will be updated quarterly and as needed. 4. LN and ED will be responsible to ensure the corrections are kept up to date and completed.

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 observation, interview, and record review, it was determined the facility failed to ensure resident-specific interventions were determined and documented, actions or interventions were communicated to staff on each shift, and the condition was monitored with progress noted at least weekly until resolution for 4 of 6 sampled residents (#s 1, 2, 5, and 6) who experienced short-term changes of conditions. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 12/2021 with diagnoses including dementia. Observations of Resident 2, interviews with staff, and review of the resident's 01/09/25 service plan, 01/19/25 through 04/15/25 temporary service plans, progress notes, and incident investigations were conducted. The following was revealed: * 01/19/25 - Bruising to left wrist approximately 2 inches long by 1 inch wide; and * 02/11/25 – Emergency room transport for sudden leaning over in wheelchair, drooling, unable to move arms or legs. There was no documented evidence for the above short-term changes of condition that the facility determined what resident-specific actions or interventions were needed for the resident, communicated the determined actions or interventions to staff, and/or documented weekly progress until the condition resolved. The need to ensure actions or interventions for short-term changes of condition were documented and communicated to staff on each shift, and changes of condition were monitored with weekly progress noted through resolution was discussed with Staff 2 (RN) on 04/16/25, and Staff 1 (ED), and Staff 3 (RCC) on 04/17/25. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 01/2023 with diagnoses including dementia and congestive heart failure. The resident's most recent evaluation and current service plan available to staff, dated 04/01/25, and 01/15/25 through 04/15/25 progress notes, outside provider notes, and temporary service plans were reviewed, interviews with staff were conducted, and observations of the resident were completed. The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and/or monitoring at least weekly through resolution: * 01/22/25 – Coughing; * 02/14/25 – New medications, prednisone and senna; * 02/24/25 – Scratches on L arm; * 03/13/25 – Urinary tract infection and new medication nitrofurantoin; * 03/13/25 – New instructions for sacral wound dressing; * 04/14/25 – Diarrhea; and * Ongoing – Skin picking and open areas on arms. The need to ensure the facility determined and documented what action or interventions were needed for short-term changes of condition, communicated the interventions to staff on all shifts and monitored the short-term changes of condition at least weekly through resolution was reviewed with Staff 1 (ED) and Staff 3 (RCC) on 04/17/25 at 12:55 pm. They acknowledged the findings. 3. Resident 6 was admitted to the facility in 08/2024 with diagnoses including dementia and Parkinson’s disease. The resident's most recent evaluation and current service plan available to staff, dated 03/14/25, and 01/15/25 through 04/15/25 progress notes, outside provider notes, and temporary service plans were reviewed, interviews with staff were conducted, and observations of the resident were completed. The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and/or monitoring at least weekly through resolution: * 01/21/25 - Increased aggression including “screaming into people’s faces and going into their rooms pacing back and forth”; * 01/27/25 – Eating with his/her hands; * 02/08/25 – Assistance required with eating; * 02/13/25 - Aggression with staff; * 03/18/25 – Loose stool; * 03/22/25 – New instructions from hospice to track bowel movements; * 04/01/25 – Skin injuries to right side of head, left knee, and right arm; * 04/09/25 – Altercation with private caregiver; * 04/10/25 – Skin injury to right elbow; * 04/10/25 – Abrasion to right hip; and * 04/10/25 – Laceration to right eyebrow. The need to ensure the facility determined and documented what action or interventions were needed for short-term changes of condition, communicated the interventions to staff on all shifts and monitored the short-term changes of condition at least weekly through resolution was reviewed with Staff 1 (ED) and Staff 3 (RCC) on 04/17/25 at 12:55 pm. They acknowledged the findings. 4. Resident 1 was admitted to the facility in 10/2022 with diagnoses including severe vascular dementia with mood disturbance, dissociative personality disorder, and history of traumatic brain injury. The resident’s progress notes from 01/15/25 through 04/15/25 were reviewed, as well as temporary service plans and incident reports. The following was identified: * Resident 1 was involved in resident-to-resident altercations on: - 02/08/25 at 2:00 pm and another at 4:00 pm; and - 03/01/25 at 7:13 pm. There was no documented evidence actions or interventions were determined, the determined interventions were communicated to staff on each shift, or that the interventions were monitored for effectiveness at least weekly through resolution for the resident-to-resident altercations. The need to determine actions or interventions for changes of condition, communicate those interventions to staff on all shifts, and to monitor the interventions for effectiveness, with progress noted at least weekly through resolution, was discussed with Staff 1 (ED) and Staff 3 (RCC) on 04/17/25 at 1:50 pm. They acknowledged the findings. No additional information was provided.

1. Regarding residents #1,2, 5 & 6 and the monitoring of their changes of condition. #2- referencing bruising and information for a trip to the hospital. LN will educate Med Tech’s to not only progress note, but to also convey directly to LN/ED to allow for follow through on provisions of care. #5- referencing new medications, skin conditions, loose bowel movements. LN will document what action or interventions are needed for short-term changes of condition, how these interventions are communicated to staff on all shifts and monitor the short-term changes of condition at least weekly through resolution. #6- referencing his aggression, need for feed assistance, loose stool and skin injuries. LN will document what action or interventions are needed for short-term changes of condition, how these interventions are communicated to staff on all shifts and monitor the short-term changes of condition at least weekly through resolution. #1- referencing resident to resident altercations. LN will document what interventions that have worked in the past and what new interventions should be in place, then ensure staff on all shifts are communicated to regarding these interventions. LN will monitor at least weekly on effectiveness of interventions. 2. Before removing residents from alert-charting, sufficient evaluations need to be completed to ensure the interventions are effective. LN will progress note her findings of evaluation for Med Techs, RCC's and ED. 3. Alert charting monitored daily by LN or RCC. 4. LN/ED

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 411-054-0037 (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 ensure they accurately captured care time and care elements that staff were providing to each resident as outlined in each individual care plan and service plan for 5 of 7 sampled residents (#s 1, 2, 4, 5, and 6) whose Acuity Based Staffing Tool (ABST) was reviewed. Findings include, but are not limited to: The facility's ABST was reviewed during the survey, 04/15/25 through 04/17/25. Review of Residents 1, 2, 4, 5, and 6’s ABST revealed multiple ADLs were not reflective of the residents' evaluated care needs. The need to ensure the facility's ABST addressed all evaluated care needs of residents, including the amount of staff time needed to provide care, was reviewed with Staff 1 (ED) and Staff 3 (RCC) on 04/17/25. They acknowledged the findings.

1. Regarding the times entered on the ABST for ADLs being incorrect based on observation from the survey team. Times for residents #1,2,4,5 & 6 were not reflective of their individual needs. When change of condition or any assessment is done for a resident, the ABST will be updated to accurately reflect the time need to care for the resident. 2. LN/ED’s had training on ABST best practices and individual areas of concern on 4.30.25. There will be a form for care staff to accurately communicate times needed for ADL’s. This will be used as a resource during the resident’s assessments and service planning as well. LN will reflect any changes of condition as needed in the ABST. 3. This will be evaluated during a change of condition, quarterly or as needed with medication changes. 4. LN/ED/RCC’s

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 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C231.

Refer to C231

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 C252, C260, C270 and C362.

Refer to C252, C260, C270 and 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: