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 reflective of residents' current care needs and provided clear directions to staff regarding the delivery of services for 3 of 5 sampled residents (#s 1, 2 and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 10/2024 with diagnoses including atherosclerosis, atrial fibrillation, and dementia. Observations of the resident, interviews with staff, and review of the resident's most recent service plan dated 04/03/25 were completed. The following areas were not reflective of residents’ current care needs and/or failed to provide clear directions to staff regarding the delivery of services: * Dressing; * Grooming; * Toileting; * Bathing; and * Behaviors including interventions for staff. On 04/23/25 at 11:50 am the need to ensure service plans were reflective of current needs and provided clear direction to staff was discussed with Staff 2 (Wellness Director) and Staff 3 (Assistant Wellness Director). They acknowledged the findings. 2. Resident 1 moved into the facility in 10/2023 with diagnoses including anxiety and insomnia. The resident’s 04/15/25 service plan and temporary service plans dated 01/21/25 to 04/21/25 were reviewed, interviews with staff and the resident were conducted, and observations of the resident were made. The service plan was not reflective of the resident’s needs and preferences and/or did not provide clear directions to staff in the following areas: * Use of call light when resident woke up on night shift; * Preference for meals delivered to apartment; * Meal preferences, including foods cut up, soft, moist food, and food and beverage preferences; * Inconsistent recall of spouse passing and instructions to staff; * Level of participation in activities. The need to ensure service plans were reflective of needs and preferences and provided clear directions to staff was discussed with Staff 3 (Assistant Wellness Director/RCC) and Staff 4 (RN) on 04/23/25. They acknowledged the findings. 3. Resident 2 moved into the facility in 06/2023 with diagnoses including atrial fibrillation, stroke and mild cognitive impairment, and was identified in the acuity interview as a high fall risk with recent noninjury falls. The resident’s 02/05/25 service plan and 01/21/25 to 04/21/25 temporary service plans were reviewed, interviews with staff and the resident were conducted, and observations of the resident were made. The service plan was not reflective of the resident’s needs and preferences and/or did not provide clear directions to staff in the following areas: * Resident-specific fall interventions; * Behaviors, including care refusals; * Communication skills, including word-finding difficulties; * Staff instructions related to monitoring and blood thinning medications; * Evacuation instructions; and * Wake-up time and breakfast routine. The need to ensure service plans were reflective of resident needs and preferences and provided clear directions to staff was discussed with Staff 3 (Assistant Wellness Director) and Staff 4 (RN) on 04/23/25. They acknowledged the findings.

1. Service plans for resident's identified in tag have been updated with information requested. 2. The assessments in the software system utilized by the facility include all check-points required. The Resident Care Coordinator has been in-serviced on what is required to be included in each service plan. The administrator has taken the Nurse Learn courses modules 18, 19, 21 and 22 related to care planning. The service plans going forward will be reviewed by the RCC, Wellness Director and Administrator to ensure all aspects of resident care are supported and addressed. 3. The corrections will be monitored with each service plan held every 90 days. The current service plans in place will be audited at random once weekly to find any potential improvements to be made.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 1 sampled resident (#2) who was administered an anticoagulant medication. Findings include, but are not limited to: Resident 2 moved into the facility in 06/2023 with diagnoses including atrial fibrillation, stroke and mild cognitive impairment. The resident’s 03/01/25 to 04/21/25 MARs and current physician orders were reviewed. The following was identified: The resident had an order for Warfarin 7.5 mg, take 0.5 tablet every Tuesday and Thursday, and take one tablet by mouth every Monday, Wednesday, Friday, Saturday and Sunday. Review of the MAR showed the medication was not administered from 03/26/25 to 04/02/25, 04/04/25, 04/09/25 and 04/10/25. The reason given on the MAR was “medication on order.” At 12:36 pm on 04/22/25 Staff 10 (MT) confirmed staff did not order the medication and it did not get administered from 03/26/25 to 04/02/25. At 2:28 pm on 04/22/25 Staff 2 (Wellness Director) stated the medication did not get administered on 04/04/25, 04/09/25, and 04/10/25 due to the MT on duty was not able to find it. At the time of the survey, the resident was receiving the medication as prescribed. The need to ensure medication orders were carried out as prescribed was discussed with Staff 3 (Assistant Wellness Director) and Staff 4 (RN) on 04/23/25. They acknowledged the findings.

1. This medication error was found by facility staff prior to the department survey team entering the facility. The actions that were in place included obtaining the medication from the pharmacy, scheduling the resident to have additional testing for INR as needed, reporting the error to APS, and conducting training for all med-techs regarding the importance of having all medications in building at all times. 2.The error was found by facility when performing previously scheduled and routine audits for missing medications. 3. The Resident Care Coordinator will continue to perform daily reports at the clinical meeting to identify any medications that were missing from the previous day. The wellness director will follow up with each med-tech for any missing medications. 4. The RCC will be responsible to perform daily medication administration audits, and the Wellness Director will be responsible to review weekly, the administrator will fill in for wellness director as needed.

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 the acuity-based staffing tool (ABST) accurately captured care time and care areas that staff were providing to each resident for 3 of 5 sampled resident (#s 2, 4 and 5) whose ABSTs were reviewed. Findings include, but are not limited to: The ABSTs, current service plans for Residents 2, 4 and 5 were reviewed, interviews with residents and staff were conducted, and observations of residents were made. The residents’ ABSTs did not accurately reflect care areas and time staff provided care to the residents. The need to ensure the ABST accurate captured care time and care areas that staff provided to residents was discussed with Staff 3 (Assistant Wellness Director) and Staff 4 (RN) on 04/23/25. They acknowledged the findings.

1. The ABST for named residents was updated immediately. 2. The RCC, Administrator, and wellness director scheduled additional training through the department's ABST coordinators. 3. The ABST will continue to be updated weekly after service plans have been held. (Service plans are held on Tuesday and Thursday's) The Administrator will review the report each Friday to ensure that service plans have been updated, and the clinical meeting will discuss any changes that have been made. In addition the Administrator and RCC will review any resident changes during the week on Friday's and ensure that the ABST is updated with new information. 4. The resident care coordinator is responsible for ensuring that the ABST is up to date with routine service plans, the administrator is responsbile for reviewing and ensuring that the RCC updated the ABST.

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure documentation that 2 of 2 newly hired staff demonstrated competency in assigned job duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed with Staff 3 (Assistant Wellness Director) at 10:00 am on 04/22/25. There was no documented evidence Staff 5 (MT), hired 12/18/24, and Staff 7 (MT), hired 02/14/25, demonstrated competency in providing assistance with ADLs and medication pass duties within 30 days of hire. Staff 5’s MT competencies were documented as completed 02/24/25. Staff 7’s MT competencies were documented as completed 03/24/25. At 10:00 am on 04/22/25, Staff 3 confirmed the competencies were not completed within 30 days of hire. The need to ensure staff demonstrate competency in any duty they were assigned within 30 days of hire was discussed with Staff 3 and Staff 4 (RN) on 04/23/25. They acknowledged the findings.

1. The facility completed the competency checklists for each of the named staff. An audit of all staff members was completed to ensure competency checklists were finished for all members. 2. The pre-service training checklist has been updated to include the competency skills checklist for each new employee, in addition the pre-service checklist must be reviewed by the RCC, the Business office manager, and then by the administrator to ensure completion. 3. The checklists of all new hires will be monitored monthly during the monthly Quality Assurance meetings. 4. The business office manager will be responsible to track the pre-service trainings, and follow up each month at the QA meeting to ensure that all components of training are completed by all new hires.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the interior of the facility was free from unpleasant odors. Findings include, but are not limited to: During the survey of 04/21/25 through 04/23/25 pervasive, unpleasant odors were identified in multiple areas of the facility. The areas identified were discussed with Staff 1 (Administrator) on 04/22/25 at 11:00 am and Staff 2 (Wellness Director) and Staff 3 (RCC) on 04/23/25 at 11:50 am. They acknowledged the findings.

1. The apartments with odor have been identified and were immediately cleaned by housekeeping team. The root cause of the odor was likely soiled garbage that had not been removed from the apartments. 2. Service plans for each of the identified residents has been updated to include 3 checks daily to ensure that soiled garbage is removed, and any soiled laundry is also removed. 3. The area will be monitored daily by facility department managers with a daily walk-through. 4. The maintenance/housekeeping manager and the administrator will be responsible to ensure that the odors are managed.