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 observation, interview and record review, it was determined the facility failed to ensure resident physical altercations were reported to the local SPD office, injuries of unknown cause were reported to the local SPD office as suspected abuse, unless an immediate facility investigation reasonably concluded and documented that the injury was not the result of abuse, and promptly investigate reports of abuse or suspected abuse related to unwitnessed falls for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose incidents were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 08/2023 with diagnoses including Alzheimer’s disease. The resident's medical records including Narrative Charting notes, dated 06/11/24 through 09/06/24, Occurrence Reports, dated 06/10/24 through 08/27/24, and faxes to Resident 1's physician were reviewed. Staff were interviewed and the resident was observed. a. The following incidents were not investigated by the facility, or the investigation lacked documentation of how abuse was ruled out: * 07/18/24: Staff found the resident on the ground in the secure courtyard; * 07/27/24: Staff faxed the physician of an unwitnessed fall; and * 08/03/24: Resident 1 was found on the floor, stated s/he fell, and sustained a skin tear to his/her right elbow. b. There was no documented evidence the facility reported the following resident to resident altercations to the local unit: * 07/23/24; and * 08/26/24. c. There was no documented evidence the facility investigated the following injuries of unknown cause, identified on 08/26/24, and if abuse or suspected abuse could not be ruled out, notified the local unit: * Bruising to Resident 1's right side of his/her forehead; and * An injury on his/her right pinky finger. The survey team requested that the facility report the incidents to the local SPD office. Confirmation of the reports were received prior to survey exit. The need to ensure the facility immediately report and promptly investigate incidents of abuse or suspected abuse was discussed with Staff 1 (Connections for Living Director) and Staff 2 (Director of Health Services) on 09/12/24 at 1:15 pm. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 08/2024 with diagnoses including Alzheimer’s disease and repeated falls. The resident's medical records including Narrative Charting notes, dated 08/03/24 through 09/06/24, Occurrence Reports, dated 08/03/24 through 09/02/24, and faxes to Resident 3's physician were reviewed. Staff were interviewed and the resident was observed. The following falls and/or injuries/incidents were not investigated by the facility or the investigation lacked documentation of how abuse was ruled out: * 08/02/24: Non-injury fall; * 08/03/24 at 12:35 am: Non-injury fall; * 08/03/24 at 11:45 am: Non-injury fall; * 08/05/24 at 4:50 am: The resident reported his/her right arm “hurt”; * 08/05/24 at 3:45 pm: Non-injury fall; * 08/06/24 at 5:40 am: Staff reported an "old scabbed abrasion over [his/her] Right eye was re-opened"; * 08/06/24: Non-injury fall per staff documentation in a progress note at 4:15 pm that the resident was “found on the floor”; * 08/09/24 at 12:00 am: Non-injury fall; * 08/09/24 at 3:30 pm: The resident reported hitting his/her head and was sent to the Emergency Department (ED); * 08/10/24: Non-injury fall; * 08/15/24: Staff reported a "small mark on the [left] side of [his/her] hair along [his/her] hair line" and sent the resident to the ED; * 08/18/24: Non-injury fall; * 08/19/24 at 5:35 am: Non-injury fall; * 08/19/24 at 12:38 pm: Non-injury fall; and * 08/19/24 at 9:00 pm: Staff reported a "light pink rash on [his/her] right side of [his/her] forehead.” During an interview with Staff 1 (Connections for Living Director) on 09/11/24 at 10:47 am, she confirmed Resident 1’s falls were reported on 08/15/24. However, the documentation provided did not specify which falls were reported to the local office. The survey team requested that the facility report the above listed incidents to the local SPD office. Confirmation of the reports was received prior to survey exit. The need to ensure the facility promptly investigated incidents of abuse or suspected abuse and report the falls if abuse or suspected abuse could not be ruled out was discussed with Staff 1 and Staff 2 (Director of Health Services) on 09/11/24 at 3:05 pm. They acknowledged the findings. 3. Resident 2 was admitted to the facility in 03/2021 with diagnoses including Alzheimer’s disease. Review of the resident's medical records including Narrative Charting notes, dated 06/03/24 through 09/04/24, and Outside Agency Documentation notes, dated 06/24/24 through 09/05/24, revealed the following: * On 07/08/24 an outside provider note from the hospice aide identified “R [right] forearm bruised”; * On 07/23/24 narrative charting notes indicated “blisters on [his/her] R [right] thigh.”; and * During an observation of ADL care on 09/11/24, Resident 2 groaned while Staff 20 (CG) assisted in donning his/her shirt. Staff 20 indicated “Last week I found a skin tear on [his/her] elbow…” She confirmed the skin tear was reported to the MT. Staff 20 looked at Resident 2’s right elbow and observed s/he had a small scab. An incident report for the injuries of unknown cause was requested from Staff 1 (Connections for Living Director) on 09/10/24 at 1:45 pm for the forearm bruising and blisters, and from Staff 2 (Health Services Director) on 09/12/24 at 12:35 pm for the skin tear. There was no documented evidence the injuries of unknown cause were investigated to rule out abuse or neglect. The surveyor requested the incidents be reported to the local SPD office. Verification the facility reported the injuries of unknown cause was received on 09/13/24 and 09/16/24. The need to promptly investigate all incidents to rule out abuse and/or neglect was discussed with Staff 1 and Staff 2 (Director of Health Services) on 09/12/24 at 2:55 pm. They acknowledged the findings. 4. Resident 4 was admitted to the facility in 08/2020 with diagnoses including type 2 diabetes mellitus and cerebrovascular accident. The resident's Narrative Charting notes, dated 06/03/24 through 09/08/24, and Temporary Service Plans were reviewed and the following was identified: On 08/11/24, staff noted Resident 4 was “found on the floor in [his/her] apartment”. An incident report was requested from Staff 1 (Connections for Living Director) on 09/11/24 at 8:45 am. There was no documented evidence the unwitnessed fall was investigated to rule out abuse or neglect or that the Administrator had reviewed the incident. The need to ensure there was documented evidence the Administrator reviewed all reports of abuse or suspected abuse was discussed with Staff 1 and Staff 2 (Director of Health Services) on 09/12/24 at 2:30 pm. They acknowledged the findings.

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:

1) What actions will be correct the rule violation for each example/resident? A) Residents 6 IR have been sent off to the local SPD Office 2) How will the system be corrected so this violation will not happen again? All IR's to be reviewed daily in clincial meeting with Administrator, CFLD, LPN, or RN to ensure proper reporting happens within 24 hours. 3) How often will the area needing correction be evaluated? Administrator/Designee, RN to review 4) Who will be responsible to see that the correction are completed/monitored? Administrator/Designee will ensure the corrections are completed/monitored with additional oversight from regional RN.

OAR 411-054-0034 (1-6) Resident Move-in and Eval: 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 include the following information: (A) Prior living arrangements; (B) Emergency contacts; (C) Service plan involvement - resident, family, and social supports; (D) Financial and other legal relationships, if applicable, including, but not limited to:(i) Advance directives;(ii) Guardianship;(iii) Conservatorship; and(iv) Power of Attorney. (E) Primary language; (F) Community connections; and (G) 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) 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).(b) 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.(c) 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.(d) Cognition, including:(A) Memory;(B) Orientation;(C) Confusion; and(D) Decision-making abilities.(e) Personality, including how the person copes with change or challenging situations.(f) Communication and sensory abilities including:(A) Hearing;(B) Vision;(C) Speech;(D) Use of assistive devices; and(E) Ability to understand and be understood.(g) 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.(h) Independent activities of daily living including:(A) Ability to manage medications;(B) Ability to use call system;(C) Housework and laundry; and(D) Transportation.(i) Pain pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort.(j) Skin condition.(k) Nutrition habits, fluid preferences, and weight if indicated.(l) List of treatments type, frequency, and level of assistance needed.(m) Indicators of nursing needs, including potential for delegated nursing tasks.(n) 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.(o) 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. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 3) who was reviewed. Findings include, but are not limited to: Resident 3 was admitted to the facility in 08/2024 with diagnoses including Alzheimer’s disease. The resident’s ALF/RCF Initial Screening and Resident Evaluation Tool, dated 07/30/24 was reviewed. The following required elements were not addressed: * Customary routines including eating and bathing; * Interests, hobbies, social and leisure activities; * Physical health status including list of diagnoses, medications and PRN use, visits to health practitioner(s), emergency room, hospital, or a nursing facility in the past year, vital signs if indicated by diagnoses, health problems, or medications; * Mental health issues including thought disorders or behavioral or mood problems, history of treatment; * Memory, orientation, confusion, and decision-making abilities; * Personality including how the person copes with change or challenging situations; * Ability to understand and be understood; * Activities of daily living including bowel and bladder management, personal hygiene, eating, assistive devices needed for eating; * Non-pharmaceutical interventions for pain; * Skin conditions; * Nutrition habits, fluid preferences and weight if indicated; * List of treatments; * Indicators of nursing needs including potential for delegated nursing tasks; * Emergency evacuation ability; * Complex medication regime; * History of dehydration or unexplained weight loss or gain; * Recent losses; * Unsuccessful prior placements; * Elopement risk or history; * Alcohol and drug use; and * Environmental factors that impact the resident's behavior including, but not limited to noise, lighting, room temperature. The need to ensure the facility addressed all required elements in the move-in evaluation was discussed with Staff 1 (Connections for Living Director) and Staff 2 (Director of Health Services) on 09/11/24 at 3:05 pm. They acknowledged the findings.

OAR 411-054-0034 (1-6) Resident Move-in and Eval: 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 include the following information: (A) Prior living arrangements; (B) Emergency contacts; (C) Service plan involvement - resident, family, and social supports; (D) Financial and other legal relationships, if applicable, including, but not limited to:(i) Advance directives;(ii) Guardianship;(iii) Conservatorship; and(iv) Power of Attorney. (E) Primary language; (F) Community connections; and (G) 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) 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).(b) 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.(c) 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.(d) Cognition, including:(A) Memory;(B) Orientation;(C) Confusion; and(D) Decision-making abilities.(e) Personality, including how the person copes with change or challenging situations.(f) Communication and sensory abilities including:(A) Hearing;(B) Vision;(C) Speech;(D) Use of assistive devices; and(E) Ability to understand and be understood.(g) 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.(h) Independent activities of daily living including:(A) Ability to manage medications;(B) Ability to use call system;(C) Housework and laundry; and(D) Transportation.(i) Pain pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort.(j) Skin condition.(k) Nutrition habits, fluid preferences, and weight if indicated.(l) List of treatments type, frequency, and level of assistance needed.(m) Indicators of nursing needs, including potential for delegated nursing tasks.(n) 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.(o) 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. This Rule is not met as evidenced by:

1) What actions will be taken to correct the rule violation for each example/residents A) All residents assessments has been updated by Adminsitrator, LPN, or RN. 3) How will the system be corrected so this violation will not happen again? A) administrator/designee will review report and communicate to CFL, LPN or RN to ensure proper planning of assessments. Administrator/designee to review daily in clincial meeting of assessments that are due to ensure proper follow up has been completed 4) How often will the area needing correction be evaluated? Administrator/designee will review monthly with regional RN to ensure all assessments have been completed and ensure all nessecary components are there.

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.(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 move- in 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 readily available to staff and provide clear direction regarding the delivery of services, reflective of residents' current status and care needs, and was implemented for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 08/2020 with diagnoses including type 2 diabetes mellitus and cerebrovascular accident. Resident 4's current service plan, dated 07/27/24, and Temporary Service Plans were reviewed, staff were interviewed, and observations of the resident were made. The service plan was not reflective of the resident’s needs and preferences or did not provide clear direction to staff regarding the delivery of services in the following areas: * Vision and need for glasses; * Mobility/transfer regarding wheelchair use and amount of assistance needed; * Toileting and amount of assistance needed; and * Ability to use call light. The need to ensure service plans were reflective of the resident's current care needs, and provided clear direction to staff was discussed with Staff 1 (Connections for Living Director) and Staff 2 (Director of Health Services) on 09/12/24 at 2:30 pm. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 08/2023 with diagnoses including Alzheimer’s disease. The resident’s medical record including the service plan dated 08/27/24, Temporary Service Plans, and Narrative Charting notes, dated 06/11/24 through 09/06/24, were reviewed. Resident 1 was observed and staff were interviewed. The service plan was not reflective of the resident’s needs and preferences or did not provide clear direction to staff regarding the delivery of services in the following areas: * Private caregiver, including their responsibilities, the agency they work for, and times the caregiver was at the facility; * Staff duties when the private caregiver was with the resident; * Fall status and interventions; * Behaviors, including inappropriate urination; * Identified behavior triggers; * Behavior interventions, including walking with the resident through the facility; * How the resident showed agitation prior to becoming aggressive; * Dressing preference; * Relationship with a resident of the opposite gender; * How often the staff were to provide toileting assistance; * What the resident's "reality" was, so staff did not trigger him/her; * Location of the resident's personal hygiene supplies; * What "changes" to monitor the resident for relating to memory; and * How the resident communicated to staff when s/he was in need of assistance. The need to ensure service plans were reflective of the resident’s needs and preferences as well as provided clear direction to staff was discussed with Staff 1 (Connections for Living Director) and Staff 2 (Director of Health Services) on 09/12/24 at 1:15 pm. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 08/2024 with diagnoses including Alzheimer’s disease. The resident’s medical record including the service plan dated 09/04/24, Temporary Service Plans, and Narrative Charting notes, dated 08/03/24 through 09/06/24, were reviewed. Resident 3 was observed and staff were interviewed. The service plan was not reflective of the resident’s needs and preferences or did not provide clear direction to staff regarding the delivery of services in the following areas: * Nail care; * Hair care; * Dressing; * Needing food cut up; * Transfers; * Home health visits; * Resuscitation status; * Bathing schedule; * Fall interventions; * Private caregiver, including their responsibilities, the agency they work for, and times the caregiver was at the facility; * Emergency evacuation needs; and * Toileting assistance. Additionally, the most recent service plan was not readily available to caregiving staff. The need to ensure service plans were reflective of the resident’s needs and preferences, provided clear direction to staff, and were readily available was discussed with Staff 1 (Connections for Living Director) and Staff 2 (Director of Health Services) on 09/11/24 at 3:05 pm. They acknowledged the findings. 4. Resident 2 was admitted to the facility in 03/2021 with diagnoses including Alzheimer’s disease. The resident’s medical record including the service plan, dated 07/24/24, Temporary Service Plans, and Narrative Charting notes, dated 06/03/24 through 09/04/24, were reviewed. Resident 2 was observed and staff were interviewed. The service plan was not reflective of the resident's current status, did not provide clear direction to staff, and/or was not being implemented in the following areas: * Toileting assistance needed depending on location; * Evacuation status; * How the resident communicated pain; * Use of stuffed animals or dolls for comfort; * Use of siderails including safety checks; * Instructions for when in bed including bed height and fall mat use; * Assistance with wheelchair for all mobility needs; * Pressure relief every hour while sitting in wheelchair; and * Apply zinc paste and skin repair cream mixed 50/50 after “incontinence”. The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and were implemented was discussed with Staff 1 (Connections for Living Director) and Staff 2 (Director of Health Services) on 09/12/24 at 2:55 pm. They acknowledged the findings.

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.(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 move- in 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:

1) What actions will be taken to correct the rule violation for each example/resident? A) All service plans have been updated to ensure all required compontents are met. 2) How will the sytem be corrected so this violaton will not happen again? A) Service plans due for the current month will be reviewed in clinical daily to ensure follow up is completed 3) How often will the area needing correction be evaluated? A) Administratior/designee will review monthly during quality assurance meeting to ensure timely completion. 4) Administrator/designee will oversee the corrections and monitoring. Regional RN will provide additional oversight.

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 that the facility failed to determine what actions or interventions were needed following short-term changes of condition, communicate the interventions to staff on all shifts, and document weekly progress until resolved for 3 of 4 sampled residents (#1, 2, and 3) who experienced short-term changes of condition. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 03/2021 with diagnoses including Alzheimer’s disease. The current service plan dated 07/24/24, Temporary Care Plans, Outside Agency Documentation notes, 08/2024 MAR, and Narrative Charting notes, dated 06/03/24 through 09/04/24, were reviewed. Observations and interviews with staff were completed between 09/10/24 through 09/12/24. The facility failed to determine what action or intervention was needed for the resident, communicate the action or intervention to staff on each shift, and/or document weekly progress until the condition resolved for the following conditions: * 06/28/24: “…clammy and appeared to go unresponsive and drooping on one side”; * 07/01/24: Rash to right cheek; * 07/08/24: Right forearm bruise as noted on an Outside Agency note; * 07/27/24: Gastrointestinal distress; * 07/31/24: Antibiotic for swelling of right jaw; and * 08/02/24: Medications held while unable to swallow including levothyroxine (for thyroid disease) and sertraline (for depression). The medications resumed on 08/09/24; and * 08/28/24: Weight loss of 5.2 pounds as noted on an Outside Agency note. The need to ensure the facility determined and documented what action or interventions were needed for changes of condition, the interventions were communicated to staff on all shifts, and were monitored at least weekly through resolution was discussed with Staff 1 (Connections for Living Director) and Staff 2 (Director of Health Services) on 09/12/24 at 2:55 pm. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 08/2023 with diagnoses including Alzheimer’s disease. The resident's medical records including Narrative Charting notes, dated 06/11/24 through 09/06/24, Occurrence Reports, dated 06/10/24 through 08/27/24, and faxes to Resident 1's physician were reviewed. Staff were interviewed and the resident was observed. a. The following changes of condition were identified: * 07/27/24: Unwitnessed fall; * 08/26/24: Injury found on the resident's right pinky finger; and * 08/27/24: Unable to take 8:00 am medications relating to being "extremely confused." There was no documented evidence the facility determined and documented what resident specific action or intervention was needed, the determined action or intervention was communicated to staff on each shift, and weekly progress was noted until the condition resolved. b. Resident 1 did not receive a scheduled dose of lorazepam (for anxiety/agitation) from 06/19/24 through the morning of 06/22/24. There was no documented evidence the facility monitored the resident for the missed doses until s/he received the medication on 06/22/24. The need to monitor changes of condition, which included determining and documenting what resident specific actions or interventions were needed, communicated those determined actions or interventions to staff on each shift, and documented weekly progress until the condition was resolved was discussed with Staff 1 (Connections for Living Director) and Staff 2 (Director of Health Services) on 09/12/24 at 1:15 pm. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 08/2024 with diagnoses including Alzheimer’s disease and repeated falls. The resident's medical records including Narrative Charting notes, dated 08/03/24 through 09/06/24, Occurrence Reports, dated 08/03/24 through 09/02/24, and faxes to Resident 3's physician were reviewed. Staff were interviewed and the resident was observed. The following changes of condition were identified: * 08/03/24 at 12:35 am: Non-injury fall; * 08/03/24 at 11:45 am: Non-injury fall; * 08/05/24 at 4:50 am: The resident reported his/her right arm “hurt”; * 08/05/24 at 3:45 pm: Non-injury fall; * 08/06/24 at 5:40 am: Staff reported an "old scabbed abrasion over [his/her] Right eye was re-opened"; * 08/06/24 at 4:15 pm: Non-injury fall; * 08/09/24 at 12:00 am: Non-injury fall; * 08/09/24 at 3:30 pm: The resident reported hitting his/her head and was sent to the Emergency Department (ED); * 08/10/24 at 6:15 am: Non-injury fall; * 08/15/24 at 1:58 pm: Staff reported a "small mark on the [left] side of [his/her] hair along [his/her] hair line" and sent the resident to the ED; * 08/18/24 at 5:45 am: Non-injury fall; * 08/19/24 at 5:35 am: Non-injury fall; * 08/19/24 at 12:38 pm: Non-injury fall; * 08/19/24 at 9:00 pm: Staff reported a "light pink rash on [his/her] right side of [his/her] forehead”; and * 08/26/24 - A progress note identified the resident having "swollen feet". The facility did not consistently document the identification and implementation of actions and interventions, communicate those actions and interventions to staff on each shift, or document weekly progress through resolution for each of the above identified changes of condition. The need to monitor changes of condition, which included determining and documenting what resident specific actions or interventions were needed, communicated those determined actions or interventions to staff on each shift, and documented weekly progress until the condition was resolved was discussed with Staff 1 (Connections for Living Director) and Staff 2 (Director of Health Services) on 09/11/24 at 3:05 pm. They acknowledged the findings.

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 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (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:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on interview, and record review, it was determined the facility failed to ensure an RN completed a timely assessment that documented findings, resident status, and interventions made as a result of the assessment for 1 of 1 sampled resident (# 4), who experienced significant changes of condition related to skin breakdown. Findings include, but are not limited to: Resident 4 moved into the facility in 08/2020 with diagnoses including type II diabetes mellitus and cerebrovascular accident. During the acuity interview on 09/09/24, the resident was identified to have a pressure sore on the coccyx area. The resident's current service plan, dated 07/27/24, was reviewed. Narrative Charting notes, dated 06/03/24 through 09/08/24, and Temporary Service Plans were reviewed. Staff were interviewed and observations of the resident were made. Staff documented the following in the resident's progress notes: * 09/01/24 - "resident continues to have open sore to buttocks area." In an interview with Staff 2 (Director of Health Services) on 09/11/24 at 8:55 am he acknowledged he was aware of Resident 4’s open sore to the buttocks and stated he had not documented findings until 09/09/24 when he completed an assessment of the wound. Documentation of Staff 2’s findings were provided to this surveyor on 09/11/24 at 9:55 am. Narrative charting notes dated 09/09/24 with late entry dated 09/11/24 at 9:36 am Staff 2 stated, “There were [two] areas of concern one on each side of [his/her] buttocks. Both were blanchable with a thin layered skin break.” The stage 2 pressure sore represented a significant change of condition. There was no documented evidence the facility completed a timely assessment for the significant change of condition, documented the resident status, and interventions made as a result of the assessment. On 09/12/24 at 2:30 pm, the need to ensure the facility RN completed a timely assessment for the significant change of condition was discussed with Staff 1 (Connections for Living Director) and Staff 2 (Director of Health Services). They acknowledged the findings.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (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:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by:

1) what actions will be taken to correct the rule violation for example/ Resident? A) RN has taken the significant change of condition course through Nurselearn. 2) How will the system be corrected so this violation will not happen again? Administrator/designee will review significant changes in daily clincial meeting with RN to ensure follow up has occurred 3) How often will the are needing correction be evaluated? A) Administrator/designee will review weekly to ensure significant changes are completed appropriately. 4) Who will be responsible to see that the corrections are completed/monitor? A) Administrator/designee will ensure the corrections are completed/monitored. Regional RN will provide additional oversight.

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure information and interventions provided by on-site outside providers were communicated to staff and the service plan was adjusted if necessary, for 1of 2 sampled residents (# 2) who received outside services. Findings include, but are not limited to: Resident 2 was admitted to the facility in 03/2021 with diagnoses including Alzheimer’s disease. Resident 2 was identified during the acuity interview on 09/09/24 as receiving hospice services. Review of Narrative Charting notes and Outside Agency Documentation, from 06/24/24 through 09/05/24, included the following information made by the provider: * An Outside Agency Documentation note from the hospice aide on 07/08/24 indicated the resident’s right forearm was “bruised”. In an interview on 09/10/24 at 4:10 pm, Staff 1 (Connections for Living Director) acknowledged she was not aware of Resident 2’s bruising on his/her forearm. * An Outside Agency Documentation note from the hospice nurse on 08/28/24 indicated Resident 2 had a weight loss of 5.2 pounds. In an interview with Staff 2 (Director of Health Services) on 09/10/24, he acknowledged he was not aware of Resident 2’s weight loss that was identified by the hospice nurse. The facility lacked documented evidence the information was communicated to direct care staff or the service plan was adjusted to ensure continuity of care. The need to ensure staff were informed of on-site outside provider information and the service plan adjusted if necessary was reviewed with Staff 1 (Connections for Living Director) and Staff 2 (Director of Health Services) on 09/12/24 at 2:55 pm. They acknowledged the findings.

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by:

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to establish and maintain effective infection prevention and control protocols to provide a safe, sanitary, and comfortable environment for 2 of 3 (#s 2 and 4) sampled residents who received incontinence care, multiple unsampled residents during meal service, and to have a designated "Infection Control Specialist." Findings include, but are not limited to: 1. Resident 4 moved into the facility 08/2020 with diagnoses including type 2 diabetes mellitus and cerebrovascular accident. Observations and interviews with staff during the survey identified s/he required two person assist for incontinence care. On 09/10/24 at 4:12 pm Staff 11 (CG) and Staff 18 (CG/MT) provided ADL incontinence care for Resident 4. Staff 18 provided perineal care and proceeded to put a clean brief on the resident without removing the soiled gloves or performing hand hygiene. Staff 18 placed soiled clothing in a bag and Staff 11 used wipes to clean Resident 4’s legs and then placed clean clothing on the resident without removing the soiled gloves or performing hand hygiene. The need to ensure staff consistently used universal precautions when providing incontinence care was discussed with Staff 1 (Connections for Living Director) and Staff 2 (Director of Health Services) on 09/12/24 at 2:30 pm. They acknowledged the findings. 2. In an interview on 09/09/24 at 4:30 pm, Staff 1 (Connections for Living Director) reported the facility did not have a designated individual to be the facility's "Infection Control Specialist," responsible for carrying out the infection prevention and control protocols, qualified by education, training, and experience or certification, and who had completed specialized training in infection prevention and control protocols. On 09/10/24 an Infection Control Specialist certificate was provided by Staff 1, dated 09/10/24, which indicated Staff 2 (Director of Health Services) was the designated Infection Control Specialist. The need to ensure the facility had a qualified "Infection Control Specialist" was discussed with Staff 1 and Staff 2 (Director of Health Services) on 09/12/24 at 2:30 pm. They acknowledged the findings. 3. Resident 2 was admitted to the facility in 03/2021 with diagnoses including Alzheimer’s disease. Observations and interviews with staff during the survey identified s/he required one person assist for incontinence care when in bed and two person assist with all transfers. On 9/11/24 at 11:00 am Staff 20 (CG) provided ADL incontinence care for Resident 2, who was observed lying in bed. With gloved hands, Staff 20 removed the soiled brief, provided peri-care with wipes, and with the same soiled gloves she proceeded to put on a clean brief. Without removing the soiled gloves or performing hand hygiene, she also touched the resident’s blanket, sheet, wheelchair, arm and legs, and clean pants as she and Staff 8 (CG) transferred the resident into his/her wheelchair. Staff 20 then assisted Resident 2 in donning a clean shirt and slippers, removed the soiled gloves and placed them on top of Resident 2’s dresser, donned new gloves and brushed his/her hair. No hand hygiene was observed prior to Staff 20 donning a new pair of gloves. The need to ensure staff consistently used universal precautions when providing incontinence care was discussed with Staff 1 (Connections for Living Director) and Staff 2 (Director of Health Services) on 09/12/24 at 2:55 pm. They acknowledged the findings. 4. During the survey, from 09/10/24 through 09/12/24 multiple care staff who performed universal duties, including resident ADL care, were observed to assist with meal assistance to Resident 2 and provided meal service in the dining room. Care staff were not consistently wearing aprons or some other barrier to prevent the potential for cross contamination when assisting with meal service and delivery. The need to ensure staff consistently used universal precautions when providing meal service was discussed with Staff 1 (Connections for Living Director) and Staff 2 (Director of Health Services) on 09/12/24 at 2:55 pm. They acknowledged the findings.

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by:

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure a thorough RN, PT, or OT assessment was completed prior to the use of a supportive device with restraining qualities and included in the service plan for 1 of 1 sampled resident (# 2) who used a supportive device with restraining qualities. Findings include, but are not limited to: Resident 2 was admitted to the facility in 03/2021 with diagnoses including Alzheimer’s disease. Observations of the resident and an interview with staff indicated the resident had a quarter-length side rail on the right side of his/her bed in the up position and another on the left side in the down position. The side rail was in good repair and flush with the mattress. The resident's service plan, dated 07/24/24, contained no information regarding the side rail. On 09/10/24 at 12:40 pm, an assessment for the side rail was requested. On 09/11/24 Staff 1 (Connections for Living Director) confirmed there was no documented evidence an assessment of the device with restraining qualities had been completed. She stated after talking with the hospice nurse who initiated the side rail, it was determined Resident 2 “is not using it” and the facility would have the rail removed. On 09/12/24 the surveyor observed that both side rails from Resident 2’s bed had been removed. The need to ensure supportive devices with restraining qualities were assessed by an RN, PT, or OT and were included in the resident's service plan was discussed with Staff 1 and Staff 2 (Director of Health Services) on 09/12/24 at 2:55 pm. They acknowledged the findings.

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by:

OAR 411-054-0037 (1)(2)(a)(c) Acuity Based Staffing Tool: Development (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING. Facilities must select and implement an acuity-based staffing tool (ABST) that is technology-based for determining appropriate staffing levels. Individual resident needs and care elements must be the primary consideration when developing and maintaining an ABST. Regardless of the ABST adopted, all requirements set forth in this rule and OAR 411-054-0034 (Resident Move in Evaluation) must be met. Facilities shall: (a) Select and implement the Department?s developed ABST or submit a proprietary ABST to the Department for approval as outlined in paragraph (2) of this rule. (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. (2) PROPRIETARY ABST. A facility that chooses to use a proprietary ABST must implement a Department-approved ABST that meets this rule. (a) REQUIRED ELEMENTS. The proprietary ABST the facility adopts must meet the following requirements: (A) Address and document all individual ABST care elements outlined in paragraph (3) of this rule. (B) When calculating total time, the ABST must include the care elements for each resident and staff time needed to complete each individual care element. (C) Ensure the ABST can produce a report that identifies all residents currently residing in the facility, the care elements for each of the residents, and the staff time required to complete each care element for each resident. (D) Ensure the ABST can present the total time, in minutes, required to meet the scheduled needs for all residents, 24 hours a day, seven days a week, preferably per shift, per day. (E) Identify the date the resident?s ABST evaluation was last completed. (F) If applicable, determine ABST time for both residents on a Specific Needs Contract and residents not on a Specific Needs Contract to build posted staffing plans as outlined in this rule. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to update an acuity-based staffing tool (ABST) to have an accurate number of minutes for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose ABST was reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 08/2023 with diagnoses including Alzheimer’s disease. The resident’s medical record including the service plan dated 08/27/24, Temporary Service Plans, and Narrative Charting notes, dated 06/11/24 through 09/06/24, were reviewed. Resident 1 was observed and staff were interviewed. The following areas were not reflective of the resident's current ADL assistance: * How much time was spent on ambulation; * How much time was spent on safety checks; and * How much time was spent on performing resident specific housekeeping and laundry services. The need to ensure the ABST tool addressed the amount of staff time needed to provide care was discussed with Staff 1 (Connections for Living Director) and Staff 2 (Director of Health Services) on 09/12/24 at 11:15 am. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 08/2024 with diagnoses including Alzheimer’s disease. The resident’s medical record including the service plan dated 09/04/24, Temporary Service Plans, and Narrative Charting notes, dated 08/03/24 through 09/06/24, were reviewed. Resident 3 was observed and staff were interviewed. The following areas were not reflective of the resident's current ADL assistance: * How much time was spent on ambulation; * How much time was spent on cueing or redirecting due to cognitive impairment or dementia; * How much time was spent assisting with leisure activities; * How much time was spent assisting with communication, assistive devises for hearing, vision, speech; and * How much time was spent on performing resident specific housekeeping and laundry services. The need to ensure the ABST tool addressed the amount of staff time needed to provide care was discussed with Staff 1 (Connections for Living Director) and Staff 2 (Director of Health Services) on 09/12/24 at 11:15 am. They acknowledged the findings. 3. Resident 2 was admitted to the facility in 03/2021 with diagnoses including Alzheimer’s disease. The resident’s medical record including the service plan dated 07/24/24, Temporary Service Plans, and Narrative Charting notes, dated 06/03/24 through 09/04/24, were reviewed. Resident 2 was observed and staff were interviewed. The following areas were not reflective of the resident's current ADL assistance: * How much time was spent supervising, cueing, or supporting while eating; and * How much time was spent by care staff performing resident specific housekeeping or laundry services. The need to ensure the ABST tool addressed the amount of staff time needed to provide care was discussed with Staff 1 (Connections for Living Director) and Staff 2 (Director of Health Services) on 09/12/24 at 2:55 pm. They acknowledged the findings. 4. Resident 4 was admitted to the facility in 08/2020 with diagnoses including type 2 diabetes mellitus and cerebrovascular accident. The resident’s medical record including the service plan dated 07/27/24, Temporary Care Plans, and Narrative Charting notes, dated 06/03/24 through 09/08/24, were reviewed. Resident 4 was observed and staff were interviewed. The following areas were not reflective of the resident's current ADL assistance: * How much time was spent helping with bowel and bladder management; * How much time was spent with bathing; * How much time was spent transferring in or out of bed or a chair; * How much time was spent providing treatments; * How much time was spent responding to call lights; and * How much time was spent performing resident specific housekeeping or laundry services performed by care staff. The need to ensure the ABST tool addressed the amount of staff time needed to provide care was discussed with Staff 1 (Connections for Living Director) and Staff 2 (Director of Health Services) on 09/12/24 at 2:30 pm. They acknowledged the findings.

OAR 411-054-0037 (1)(2)(a)(c) Acuity Based Staffing Tool: Development (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING. Facilities must select and implement an acuity-based staffing tool (ABST) that is technology-based for determining appropriate staffing levels. Individual resident needs and care elements must be the primary consideration when developing and maintaining an ABST. Regardless of the ABST adopted, all requirements set forth in this rule and OAR 411-054-0034 (Resident Move in Evaluation) must be met. Facilities shall: (a) Select and implement the Department?s developed ABST or submit a proprietary ABST to the Department for approval as outlined in paragraph (2) of this rule. (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. (2) PROPRIETARY ABST. A facility that chooses to use a proprietary ABST must implement a Department-approved ABST that meets this rule. (a) REQUIRED ELEMENTS. The proprietary ABST the facility adopts must meet the following requirements: (A) Address and document all individual ABST care elements outlined in paragraph (3) of this rule. (B) When calculating total time, the ABST must include the care elements for each resident and staff time needed to complete each individual care element. (C) Ensure the ABST can produce a report that identifies all residents currently residing in the facility, the care elements for each of the residents, and the staff time required to complete each care element for each resident. (D) Ensure the ABST can present the total time, in minutes, required to meet the scheduled needs for all residents, 24 hours a day, seven days a week, preferably per shift, per day. (E) Identify the date the resident?s ABST evaluation was last completed. (F) If applicable, determine ABST time for both residents on a Specific Needs Contract and residents not on a Specific Needs Contract to build posted staffing plans as outlined in this rule. 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:

1) What actions will be taken to correct the rule violation for each example/resident? A) All residents ABST care times have been reviewed and updated to ensure accurate care time. Administrator, Regional RN, Regional LPN have reviewed ABST with elderwise consultant to ensure accurate care time has been captured 2) How will the system corrected so this violation will not happened again? A) Administrator/designee will review ABST care time minutes during time of service plan/Assessment due during the month to ensure accurate care times have been captured. 3) How often will the area needing correction be evaluated? A) Adminsitrator/designee will review monthly during quality assurance meeting with RN 4) Who will be responsible to see that the corrections are completed/monitored? Administrator/designee with oversight from regional RN

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by:

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by:

1) What action will be taken to correct the rule violation for each example/resident? A) Administrator, Regional RN and Regional LPN and CFLD updated the ABST during care times. 2) How will th system be corrected so this violation will not happen again? Administrator trained CFLD , Regional RN and Regional LPN on how to update the ABST when they are making changes to the care plans to go through and update the ABST. 3) How often will the area needing correction be evaluated? Adminsitrator/designee, CFLD, RN and will review daily in clincal to ensure ABST has been appropriately updated. 4) Who will be responsible to see that the correction are completed/ Monitored? Administrator/designee will oversee with additonal oversight from regional RN.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined that the facility failed to conduct fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety records from 03/2024 through 09/2024 were reviewed. The fire drill records did not consistently include documentation of the following required components: * Escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; and * Number of occupants evacuated. Fire and life safety documentation was reviewed with Staff 5 (Maintenance Assistant) on 09/11/24 at 11:15 am. The following was noted: The facility utilized an electronic form through Direct Supply’s Technology Enabled Life Safety (TELS) system to document completed fire drills. Staff 5 acknowledged the system did not capture all required components according to the OFC. The need to ensure the facility conducted and documented fire drills according to the OFC was discussed with Staff 1 (Connections for Living Director) and Staff 2 (Director of Health Services) on 09/12/24 at 2:30 pm. They acknowledged the findings.

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

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on record review and interview, it was determined the facility failed to ensure residents were instructed on general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places within 24 hours of admission and re-instructed at least annually. Findings include, but are not limited to: On 09/11/24, Staff 5 (Maintenance Assistant) was asked to explain the process of providing resident instruction upon admission and re-instruction annually. Staff 5 stated there was no documented evidence the facility's fire drill and safety procedures were reviewed with residents upon admission nor re-instructed at least annually. The need to ensure residents were instructed on general safety procedures within 24 hours of admission and re-instructed at least annually was discussed with Staff 1 (Connections for Living Director) and Staff 2 (Director of Health Services) on 09/12/24 at 2:30 pm. They acknowledged the findings.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by:

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by:

Please refer to plan of correction for C 231, C 252, C 260, C 280, Z 163, and Z 164

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were maintained in good repair, grounds were kept orderly and free of refuse, and garbage was stored in a covered refuse container. Findings include, but are not limited to: On 09/09/24 and 09/10/24 the facility grounds were toured and the following was identified: * Multiple drop-offs measuring up to three inches were noted along pathway edges along sidewalks in the secured courtyard which created tripping hazards; * Dumpster area had debris on the ground and dumpster lids were left open; and * Outside the dumpster fencing were two office chairs and additional refuse in the bushes. On 09/11/24 at 2:15 pm the building exterior was toured with Staff 1 (Connections for Living Director) and Staff 3 (Director of Environmental Services). Staff 1 and Staff 3 acknowledged the need to ensure grounds were free of litter and refuse, and outside surfaces were maintained in good repair.

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by:

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (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 the 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. A RCF 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 will 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 environment was clean and maintained in good repair. Findings include, but are not limited to: The facility was toured on 09/09/24 at 2:25 pm and the following was observed: a. Exterior of the building: * In the secured courtyard, the door, multiple windows, siding and overhangs had cobwebs, dirt and debris. b. Interior of the building: * Multiple light fixtures near the front entrance had a collection of dead insects; * A large cobweb was hanging off the light fixture near the exit to the secured courtyard; * Four vents in the dining room on each side of the fireplace were covered with dirt and debris; * A rag was observed in the fireplace; * Multiple residents’ doors had black marks and scuffs; * The wall in the community bathroom by the fish tank had peeling paint; * Multiple chairs in the common living room and dining room were worn, stained and/or had gouges; * A chairside table in the common area had green stains; and * There were multiple scratches, dings and gouges in the wood at both common area workstations. The need to ensure the interior and exterior of the building was clean and maintained in good repair was discussed with Staff 1 (Connections for Living Director) and Staff 3 (Director of Environmental Services) on 09/11/24 at 2:15pm. They acknowledged the findings.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (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 the 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. A RCF 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 will be kept clean and in good repair. This Rule is not met as evidenced by:

OAR 411-054-0200 (7)(b-d) Housekeeping and Laundry (b) HOUSEKEEPING AND SANITATION.(A) A RCF must have a secured janitor closet for storing supplies and equipment, with a floor or service sink.(B) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.(c) LAUNDRY FACILITIES. Laundry facilities may be located to allow for both resident and staff use, when a time schedule for resident-use is provided and equipment is of residential type. When the primary laundry is not in the building or suitable for resident-use, a RCF must provide separate resident-use laundry facilities. A CF is not required to provide resident-use laundry services.(A) Laundry facilities must be operable and at no additional cost to the resident.(B) Laundry facilities must have space and equipment to handle laundry-processing needs. Laundry facilities must be separate from food preparation and other resident-use areas.(C) On-site laundry facilities, used by staff for facility and resident laundry, must have capacity for locked storage of chemicals and equipment.(D) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.(d) SOILED LINEN PROCESSING. For the purpose of this rule, "soiled linens and soiled clothing," means linens or clothing contaminated by an individual's bodily fluids (for example, urine, feces, or blood).(A) There must be a separate area with closed containers that ensure the separate storage and handling of soiled linens and soiled clothing. There must be space and equipment to handle soiled linen and soiled clothing processing needs that is separate from regular linens and clothing.(B) Arrangement must provide a one-way flow of soiled linens and soiled clothing from the soiled area to the clean area and preclude potential for contamination of clean linens and clothing.(C) The soiled linen room or area, must include a flushing rim clinical sink with a handheld rinsing device and a hand wash sink or lavatory.(D) When washing soiled linens and soiled clothing, washers must have a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant is used.(E) Personnel handling soiled laundry must be provided with waterproof gloves.(F) Covered or enclosed clean linen storage must be provided and may be on shelves or carts. Clean linens may be stored in closets outside the laundry area.(G) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure soiled linens and soiled clothing were kept in closed containers to ensure the separate storage and handling of the soiled items, a one-way flow of soiled laundry to preclude potential contamination, and washers for soiled laundry had a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant was used. Findings include, but are not limited to: During a tour of the laundry rooms on 09/10/24 at 9:05 am the following observations were made in the main laundry room: * The main laundry room had two doors to enter. The first door entered directly into the room with a flushing rim sink. A second door entered into a storage room prior to entering into the main laundry room area where non-soiled items were washed, dried and folded, and then lead into the room with a flushing rim sink; * A single residential washing machine with no indicator of rinse temperature was located in the room with the flushing rim sink; * Laundry items were soaking in the flushing rim sink; * Lying on the floor next to the flushing rim sink was a blanket, a stuffed animal, jeans, and a pair of shoes. Additionally, there was an uncovered bin of miscellaneous shoes; and * The counter next to the flushing rim sink had folded clothes, towels and rags. On 09/11/24 at 9:05 am, Staff 13 (CG) confirmed the items in the flushing rim sink were left from the overnight shift, as well as the dirty items on the floor. “I came in today and it was like this.” She confirmed the folded clothes on the counter were clean. She also indicated when she had a bag of soiled items and the flushing rim sink had items already soaking, she would leave the bag on the floor until it was available. On 09/10/24 Staff 11 (CG) and Staff 13 indicated they would enter the laundry room with a soiled bag through either door depending on where they were coming from. They entered the door leading directly into the room with the flushing rim sink if they were coming from a resident’s room in the same hallway as the first door. The second door was used if they were coming from resident rooms located on the opposite end of the facility. On 09/10/24 at 12:00 pm Staff 3 (Director of Environmental Services) confirmed the residential washing machine did not reach 140 degrees Fahrenheit, and the laundry detergent used did not have a chemical disinfectant. Following an adjustment to the water temperature, Staff 3 confirmed at 12:35 pm that the washing machine temperature reached 148.9 deg F. The need to ensure soiled items were stored in closed containers, the one-way flow of soiled laundry was utilized by staff, and washers for soiled laundry had a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant was used was discussed with Staff 1 (Connections for Living Director) and Staff 3 on 09/11/24 at 2:15 pm. They acknowledged the findings.

OAR 411-054-0200 (7)(b-d) Housekeeping and Laundry (b) HOUSEKEEPING AND SANITATION.(A) A RCF must have a secured janitor closet for storing supplies and equipment, with a floor or service sink.(B) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.(c) LAUNDRY FACILITIES. Laundry facilities may be located to allow for both resident and staff use, when a time schedule for resident-use is provided and equipment is of residential type. When the primary laundry is not in the building or suitable for resident-use, a RCF must provide separate resident-use laundry facilities. A CF is not required to provide resident-use laundry services.(A) Laundry facilities must be operable and at no additional cost to the resident.(B) Laundry facilities must have space and equipment to handle laundry-processing needs. Laundry facilities must be separate from food preparation and other resident-use areas.(C) On-site laundry facilities, used by staff for facility and resident laundry, must have capacity for locked storage of chemicals and equipment.(D) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.(d) SOILED LINEN PROCESSING. For the purpose of this rule, "soiled linens and soiled clothing," means linens or clothing contaminated by an individual's bodily fluids (for example, urine, feces, or blood).(A) There must be a separate area with closed containers that ensure the separate storage and handling of soiled linens and soiled clothing. There must be space and equipment to handle soiled linen and soiled clothing processing needs that is separate from regular linens and clothing.(B) Arrangement must provide a one-way flow of soiled linens and soiled clothing from the soiled area to the clean area and preclude potential for contamination of clean linens and clothing.(C) The soiled linen room or area, must include a flushing rim clinical sink with a handheld rinsing device and a hand wash sink or lavatory.(D) When washing soiled linens and soiled clothing, washers must have a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant is used.(E) Personnel handling soiled laundry must be provided with waterproof gloves.(F) Covered or enclosed clean linen storage must be provided and may be on shelves or carts. Clean linens may be stored in closets outside the laundry area.(G) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture. This Rule is not met as evidenced by:

OAR411-004-0020(1)(d) Individual Rights Settings Right to Freedom (1) Residential and non-residential HCB settings must have all of the following qualities: (d) The setting ensures the individual the right to freedom from restraints, except in accordance with the standards set forth in ORS 443.739, OAR chapters 309 and 411, 1915(c) HCBS Waivers, 1915(i) State Plan HCBS, or 1915(k) Community First Choice (K State Plan Option). When the right to freedom from restraints must be limited due to a threat to the health and safety of an individual or others, an individually-based limitation as described in OAR 411-004-0040 must apply in any residential or non-residential setting. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure individuals had the right to freedom from restraints. Findings include, but are not limited to the following: Refer to C 340.

OAR411-004-0020(1)(d) Individual Rights Settings Right to Freedom (1) Residential and non-residential HCB settings must have all of the following qualities: (d) The setting ensures the individual the right to freedom from restraints, except in accordance with the standards set forth in ORS 443.739, OAR chapters 309 and 411, 1915(c) HCBS Waivers, 1915(i) State Plan HCBS, or 1915(k) Community First Choice (K State Plan Option). When the right to freedom from restraints must be limited due to a threat to the health and safety of an individual or others, an individually-based limitation as described in OAR 411-004-0040 must apply in any residential or non-residential setting. This Rule is not met as evidenced by:

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to provide individual privacy in his or her own unit for multiple unsampled residents. Findings include, but are not limited to: During the survey of 09/09/24 and 09/12/24 multiple shared units were observed to have a shared bathroom without the ability to lock the door. In a tour with Staff 1 (Connections for Living Director) on 09/10/24 at 12:33 pm it was confirmed the shared units did not have a lockable bathroom door. On 09/10/24 at 12:33 pm Staff 1 confirmed the facility had ordered locks for the units with a shared bathroom. The inability to lock bathroom doors in a shared unit jeopardized residents' rights to privacy and dignity. The need to ensure residents were provided with individual privacy in his or her own unit was discussed with Staff 1, and Staff 2 (Director of Health Services) on 09/12/24 at 2:30 pm. They acknowledged the findings.

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

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the individual residents had a key to access the unit for multiple sampled and unsampled residents. Findings include, but are not limited to: During an interview on 09/10/24 at 10:40 am, Staff 1 (Connections for Living Director) confirmed the majority of the residents did not have keys to their units and Staff 1 was not aware keys needed to be provided. Review of Resident 1, 2, 3, and 4’s service plans did not state whether or not residents had been provided a key. The need to ensure the individual residents had a key to access their unit was discussed with Staff 1 and Staff 2 (Director of Health Services) on 09/12/24 at 2:30 pm. No additional information was provided.

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by:

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C231, C295, C361, C420, C422, C510, C513, and C530.

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:

Please refer to plan of correction for C 252, C 260, C 280, C 362, and C 363.

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 6, 9, 10, and 17) completed all pre-service orientation training prior to beginning their job responsibilities, and 3 of 3 newly hired direct care staff (#s 9, 10, and 17) completed all required pre-service dementia trainings and demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed from 09/10/24 through 09/12/24. The following was identified: a. There was no documented evidence Staff 6 (Housekeeping), hired 04/25/24, Staff 9 (CG), hired 07/22/24, Staff 10 (CG), hired 06/25/24, and Staff 17 (CG), hired 07/03/24, completed required pre-service orientation training prior to beginning job duties in one or more of the following areas: * Abuse reporting requirements; * Fire safety and emergency procedures; * Written job description; * Infectious disease prevention; and * Home and Community-Based Services. b. There was no documented evidence Staff 9, Staff 10 and Staff 17 completed one or more of the following pre-service dementia training topics: * Environmental factors that are important to a resident's well-being (e.g., staff interactions, lighting, room temperature, noise, etc.); * Family support and the role the family may have in the care of the resident; * How to provide personal care to a resident with dementia, including an orientation to the resident's service plan; and * Use of supportive devices with restraining qualities in memory care communities. c. There was no documented evidence Staff 9, Staff 10 or Staff 17 demonstrated competency in one or more assigned duties within 30 days of hire: * Role of service plans in providing individualized care; * Changes associated with normal aging; and * Identification, documentation, and reporting changes of condition. The need to ensure newly hired staff completed all pre-service orientation and dementia training prior to performing job duties, and direct care staff demonstrated competency in all assigned duties within 30 days of hire was discussed with Staff 4 (Business Office Manager) on 09/11/24 at 2:40 pm and Staff 1 (Connections for Living Director) on 09/12/24 at 8:35 am. They acknowledged the findings.

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. 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, C280, C290 and C340.

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:

Please refer to plan of correction for C 252, C 260, C 280, C 362, and C 363.

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was developed for each resident and was included in the service plan for 3 of 4 sampled residents (#s 1, 2, and 3) whose nutrition and hydration plans were reviewed. Findings include, but are not limited to: Residents 1, 2, and 3’s current service plans were reviewed during survey. Each service plan lacked information and/or staff instructions related to the individualized nutrition and hydration status, preferences, and needs of the resident. The need to develop an individualized nutrition and hydration plan based on the resident's preferences and needs that was individualized and documented in the resident's service plan was discussed with Staff 1 (Connections for Living Director) and Staff 2 (Director of Health Services) on 09/11/24 and 09/12/24. They acknowledged the findings.

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

1) What actions wil be taken to correct the rule violation for each example/resident? A) All resident nutrion and Hydration plans have been updated by RN, LPN and CFLD to ensure accuracy of plan with their appropriate diet. 2) How will the system be corrected so this violation will not happen again? Administrator/designee will review hydration and nutrion plans with RN during clincial meeting to ensure they are accurate. 3) How often will the area needing correction be evaluated? A) System will be reviewed monthly during quality assurance with administrator/designee and RN 4) Who will be responsible to see that the corrections are completed/monitored? A) Administrator/designee will see the correctios are completed/monitored. Regional RN will provide additonal oversight.

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure the activity evaluation addressed all required components and an individualized activity plan was developed based on the activity evaluation, for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose activity plans were reviewed. Findings include, but are not limited to: Resident 1, 2, 3, and 4's records were reviewed and observations were made during the survey. The current activity evaluations did not address one or more of the following required components: * Past and current interests; * Current abilities and skills; * Emotional/social needs and patterns; * Physical abilities and limitations; * Adaptations needed to participate; and * Identification of activities for behavioral interventions. The current activity plans were not individualized to each resident based on their activity evaluation and not included on the resident's activity service or care plan. In an interview with Staff 16 (Activities) on 09/11/24 at 8:02 am, she confirmed the residents did not have an activity evaluation. The need to ensure activity evaluations addressed all required components and individualized activity plans were developed was discussed with Staff 1 (Connections for Living Director) and Staff 2 (Director of Health Services) on 09/11/24 and 09/12/24. They acknowledged the findings.

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by:

1) What actions will be taken to correct the rule violation for each example/resident? A) Administrator partnered with activities director to help update and assist with each activity assessent to be updated to accurately reflect the activity needs 2) How will the system be corrected so this violation will not happen again? A) System will be reviewed during clincial meeting to ensure that activity assessments are being done in a timely manner with all required compontents. 3) How often will the area needing correction be evaluated? A) Administrator/designee will review during monthly quality assurance meeting with RN. 4) Administrator/designee will ensure the corrections are being completed/monitored. With Regional RN as additional oversight.

OAR 411-057-0160(e) Behavior (e) Behavioral symptoms which negatively impact the resident and others in the community must be evaluated and included on the service or care plan. The memory care community must initiate and coordinate outside consultation or acute care when indicated. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to provide an individualized service plan for behavioral symptoms that negatively impacted the resident or others in the community for 1 of 1 sampled resident (# 1) with documented behaviors. Findings include, but are not limited to: Resident 1 was admitted to the facility in 08/2023 with diagnoses including Alzheimer’s disease. The resident's medical records including Narrative Charting notes, dated 06/11/24 through 09/06/24, Occurrence Reports, dated 06/10/24 through 08/27/24, and faxes to Resident 1's physician were reviewed. Staff were interviewed and the resident was observed. Per record review and interview, Resident 1 was identified as having behaviors including agitation, physical aggression, and inappropriate urination. The resident's service plan did not address all of the behaviors and lacked individualized interventions to assist staff in minimizing the negative impact of the behaviors. The need to develop individualized behavior plans for residents with behavioral symptoms which negatively impacted the resident or others in the community was discussed with Staff 1 (Connections for Living Director) and Staff 2 (Director of Health Services) on 09/12/24 at 1:15 pm. They acknowledged the findings.

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

OAR 411-057-0170(6) Secure Outdoor Recreation Area (6) SECURE OUTDOOR RECREATION AREA. The memory care community must comply with facility licensing requirements for outdoor recreation areas as well as the following standards. These requirements apply to newly endorsed, constructed, or remodeled communities which have construction documents approved on or after November 1, 2010 with the exception of subsections (d) and (e) of this section. (a) The space must be a minimum of 600 square feet or 15 square feet per resident, whichever is greater and is exclusive of normal walkways and landscaping. The space must have a minimum dimension of 15 feet in any direction; (b) Fences surrounding the perimeter of the outdoor recreation area must be no less than six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition; (c) Walkways must meet the accessibility requirements of the Oregon Structural Specialty Code. Walkway surfaces must be a medium to dark reflectance value to prevent glare from reflected sunlight; (d) Outdoor furniture must be sufficient weight, stability, design, and be maintained to prevent resident injury or aid in elopement; and (e) Doors to the outdoor recreation area may be locked during nighttime hours or during severe weather per facility policy. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure outdoor furniture was of sufficient weight, stability and design, to prevent resident injury or aid in elopement. Findings include, but are not limited to: The secured courtyard of the memory care community was toured on 09/09/24 at 2:25 pm. Multiple outdoor chairs were observed in the courtyard, to which residents had free access. The furniture was movable, and not of sufficient weight to prevent injury or elopement. On 09/09/24 at 4:45 pm the outdoor courtyard was toured with Staff 1 (Connections for Living Director) and the identified furniture was removed. The need to maintain outdoor furniture of sufficient weight was discussed with Staff 1 and she acknowledged the findings.

OAR 411-057-0170(6) Secure Outdoor Recreation Area (6) SECURE OUTDOOR RECREATION AREA. The memory care community must comply with facility licensing requirements for outdoor recreation areas as well as the following standards. These requirements apply to newly endorsed, constructed, or remodeled communities which have construction documents approved on or after November 1, 2010 with the exception of subsections (d) and (e) of this section. (a) The space must be a minimum of 600 square feet or 15 square feet per resident, whichever is greater and is exclusive of normal walkways and landscaping. The space must have a minimum dimension of 15 feet in any direction; (b) Fences surrounding the perimeter of the outdoor recreation area must be no less than six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition; (c) Walkways must meet the accessibility requirements of the Oregon Structural Specialty Code. Walkway surfaces must be a medium to dark reflectance value to prevent glare from reflected sunlight; (d) Outdoor furniture must be sufficient weight, stability, design, and be maintained to prevent resident injury or aid in elopement; and (e) Doors to the outdoor recreation area may be locked during nighttime hours or during severe weather per facility policy. This Rule is not met as evidenced by: