OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(B) Delegation and Teaching. Delegation and teaching must be provided and documented by a RN in accordance with the Oregon Administrative Rules adopted by the Oregon State Board of Nursing in chapter 851, division 047. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules for 2 of 2 sampled residents (#s 1 and 2) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to: Pursuant to OAR chapter 851, division 006, delegation process means the process utilized by an RN to authorize a UAP to perform a nursing procedure for a client, the outcome of which the RN retains accountability for. The RN must document all delegation process decisions, actions, and outcomes pursuant to OAR 851-045 including comprehensive assessment and reasoned conclusions that identify client problems and risks, educate the UAP, evaluate their learned knowledge, and provide step-by- step education and evaluation experience with the UAP and the client. Resident 1 moved into the facility in 04/2020, and Resident 2 moved into the facility in 02/2017. Both residents had diagnoses including insulin dependent diabetes. Resident 1 and 2’s MARs, dated 11/01/24 through 11/22/24, were reviewed and revealed insulin had been given by Staff 3, 4 and 5 (MTs) on multiple occasions. Delegation records for Residents 1 and 2 were reviewed on 11/21/24 and 11/22/24 and revealed the following: a. An initial delegation was completed for Staff 3 on 10/31/24. There was no documentation by Staff 2 (RN) that one or more of the following elements were determined for Resident 1 or Resident 2: * Resident did not require assessment during the nursing procedure; * Performance of the nursing procedure did not require independent decision making; * Procedure was reasonably predictable; * The consequences of the UAP performing the nursing procedure were not life threatening and posed minimal risk to the resident; * The environment of care supported the safe performance of the nursing procedure; * The nursing procedure would be performed by UAP at a frequency that allowed for continued safe performance; * UAP communicated they were willing and able to perform the procedure for the resident; and * RN had the appropriate resources necessary to fulfill nursing practice and delegation responsibilities including availability to provide assessment of resident and ongoing competency validation of UAP’s performance. Additionally, the delegation records were missing the following required documentation: * Step-by-step evidence-based instructions, including how to perform the nursing procedure and infection control practices to follow; * Documentation that the RN addressed questions the UAP and resident may have; and * Health problems that may impact the resident’s condition related to delegated nursing procedure. b. Periodic inspection and evaluation was completed for Staff 4 on 9/18/24 and Staff 5 on 9/23/24. Delegation lacked documentation that some or all of the following requirements were met for Residents 1 or 2: * Resident did not require assessment during the nursing procedure; * Performance of the nursing procedure did not require independent decision making; * Procedure was reasonably predictable; * The consequences of the UAP performing the nursing procedure were not life threatening and posed minimal risk to the resident; * The environment of care supported the safe performance of the nursing procedure; * The nursing procedure would be performed by UAP at a frequency that allowed for continued safe performance; and * RN had the appropriate resources necessary to fulfill nursing practice and delegation responsibilities including availability to provide assessment of resident and ongoing competency validation of UAP’s performance. Additionally, there was no documentation that Staff 2 (RN) verified Staff 4 and 5’s documentation. The need to ensure nursing delegation and teaching to facility UAPs was provided and documented by an RN in accordance with the OARs adopted by the OSBN in chapter 851, division 047 was reviewed with Staff 1 (Administrator of Wellsprings) and Staff 2 (RN) on 11/22/24 at 4:20 pm. Staff 2 acknowledged the delegation documentation was lacking components of OSBN Division 47 and stated he would update the delegations.

It was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules for 2 of 2 sampled residents (#s 1 and 2) who received insulin injections by unlicensed facility staff. 1. For Residents 1 & 2 (and all other residents) RN delegations will be revised to include documentation of required elements. • Resident Assessments including a review of any related health concerns that could impact the ability to complete the procedure safely determining that: o The resident's condition is stable and predictable o The rationale for why the delegated task can be safely performed. o The consequences of the UAP performing the nursing procedure are not life threatening and pose minimal risk to the resident. o The Resident does not require a new assessment each time the procedure is performed. o The performance of the nursing procedure does not require independent decision making from the UAP. • Educating the UAP through providing information about the nursing procedure and why it is necessary in the management or treatment of the resident’s condition, possible risks, adverse side effects possible including how and when to report any adverse effects. • Providing step by step instructions outlining how to complete the procedure including appropriate infection control processes. • The rationale for the determination of the UAP’s suitability to safely and appropriately perform the delegated procedure in the evironment of care. • The nursing procedure will be performed by the UAP at a frequency that allows for continued safe performance. • The UAP agrees that they are willing and able to perform the procedure for the Resident. • The residents and UAP had the opportunity to ask questions to ensure understanding of the procedure. • The RN has directly observed the UAP’s performance of the procedure. • RN rationale for determining frequeny of periodic reassessments of resident and ongoing competency validations of UAP's performance. • RN is willing and able to engage in ongoing nursing practice with the resident. 2. Facility RN and Facility Administrator received education on the Board of Nursing delegation requirements found in Division 47 and are implementing the use of compliant delegation forms. 3. Facility Administrator or designee will perform a weekly audit of delegation documentation for 12 weeks to determine that all required elements are present and that reviews are taking place at the required intervals. 4. The Facility RN and Administrator are responsible to ensure corrections are completed and maintained.

OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(B) Delegation and Teaching. Delegation and teaching must be provided and documented by a RN in accordance with the Oregon Administrative Rules adopted by the Oregon State Board of Nursing in chapter 851, division 047. This Rule is not met as evidenced by:

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled medication technicians (#s 3, 4 and 5) demonstrated knowledge and performance in any duty they were assigned prior to providing care services to residents, and 2 of 3 medication technicians (#s 4 and 5) completed First Aid certification and abdominal thrust training. Findings include, but are not limited to: Staff 3 (MT) was hired 10/21/24, Staff 4 (MT) was hired 06/19/24, and Staff 5 (MT) was hired 06/18/24. A desk review of employee training records on 11/21/24 and 11/22/24, and a telephone interview with Staff 1 (Administrator of Wellsprings) on 11/22/24 at 12:55 pm revealed the following: * Staff 3 (MT) was hired 10/21/24. Staff 3 had been working independently in the facility as a MT, which included administering medications to residents. Her MT training documentation had not been completed until 11/20/24; * Staff 4 (MT) was hired 06/19/24. Staff 4 had been working independently in the facility as a MT, which included administering medications to residents. Her MT training documentation had not been completed until 11/20/24; * Staff 5 (MT) was hired 06/18/24. Staff 4 had been working independently in the facility as a MT, which included administering medications to residents. Her MT training documentation had not been completed until 11/19/24; and * Staff 4 and 5 lacked documented evidence of abdominal thrust and First Aid training. The need for the facility to have a system to ensure staff training was completed and documented within the required time frame was reviewed with Staff 1 on 11/22/24. She acknowledged the findings. She stated all facility MTs would not administer medications until documented training was completed.

It was determined the facility failed to ensure 3 of 3 sampled medication technicians (#s 3, 4 and 5) demonstrated knowledge and performance in any duty they were assigned prior to providing care services to residents, and 2 of 3 medication technicians (#s 4 and 5) completed First Aid certification and abdominal thrust training. 1. Staff 3, 4, 5. • Staff competency documentation was located after survey exit. o Competencies previously completed were redone on 11/20/24. o All staff completed Abdominal Thrust and First Aid Training. 2. • Facility implemented an onboarding process checklist to ensure all required training items are completed timely. • Facility is utilizing file organizers and tracking spreadsheets to monitor compliance with training requirements. 3. The Administrator or designee will: • Review the onboarding checklist for each new hire ongoing to ensure that all state required trainings are completed, within the required timeframe, and the supporting documents are placed in the employee file. • Randomly audit 5 employee files weekly for 3 months then monthly ongoing for evidence of completion of the required trainings and demonstrations of competency within 30 days of hire. 4. The Administrator is responsible to ensure corrections take place and are maintained.

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: