OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear directions to staff regarding the delivery of services for 2 of 6 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 11/2023 with diagnoses including vasomotor rhinitis, chronic atrial fibrillation, sensorineural hearing loss, and presence of cardiac pacemaker. Interviews with the resident and facility staff were conducted during the survey. Resident 1's service plan, dated 09/23/24, was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Number of staff needed to assist with activities of daily living and emergency evacuations; * Instructions for bleeding precautions and interventions while on anticoagulation therapy; * Instructions on edema management; * Pacemaker precautions, instructions for proper maintenance, and how to monitor malfunctions; * Instructions on specific changes of condition to report to hospice; * Schedule and type of services provided by private caregiver; and * Resident self-administration of medication. The need to ensure the service plan reflected residents' current care needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (General Manager), Staff 2 (Health and Wellness Manager), and Staff 6 (Health and Wellness Nurse) on 10/04/24 at 10:55 am. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 02/2024 with diagnoses including type 2 diabetes mellitus, atrial fibrillation, end stage renal disease, and major depressive disorder. Interviews with the resident and facility staff were conducted during the survey. Resident 3's service plan, date 09/12/24, was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Dialysis port monitoring and precautions; * Instructions for signs and symptoms of complications to report while monitoring dialysis port; * Dialysis schedule and transportation days; * Instructions on signs and symptoms of depression to report while on anti-depressant therapy; * Instructions for bleeding precautions and interventions while on anticoagulation therapy; * Instructions to staff on blood glucose monitoring protocol when the resident skipped meals; * Instructions on signs and symptoms of hypo- and hyperglycemia to report; * Electric wheelchair equipment precautions and instructions for proper maintenance; * Self-administration medications, including preparation and administration of insulin subcutaneous injections; and * Pain management. The need to ensure the service plan reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (General Manager), Staff 2 (Health and Wellness Manager), and Staff 6 (Health and Wellness Nurse) on 10/04/24 at 10:55 am. They acknowledged the findings.

OAR 411-054-0036 (1-4) Service Plan: General 1. A. For resident #1, service plan was updated to reflect resident's care needs, diagnosis's, current medication regimen and treatments, along with detailed instructions of what to do if any complications arise, who to notify, and when to contact hospice if appropriate. RN/hospice has added precautions and resident specific interventions in eMAR for medications such as diuretics, blood thinners, psychotropic medications, pain medications for this resident. Upon admission, and every 90-days, RN to assess the resident’s ability to self-administer medications. Facility has MD order for the medication, order for self-administration in place, and RN assessment completed. For resident #1, pacemaker precautions, instructions for proper maintenance, and how to monitor/report malfunctions information added to service plan. Resident #1’s personal caregiver schedule added and what services are provided and whom she works for added into service plan. Due to hospice status, RN has detailed when staff need to contact hospice due to any changes in conditions. B. For resident #3, service plan was updated to reflect resident's care needs, diagnosis's, current medication regimen and treatments, along with detailed instructions of what to do if any complications arise, who to notify, and when to contact EMS if appropriate. RN has added precautions and resident specific interventions in eMAR for medications such as diuretics, blood thinners, psychotropic medications, pain medications, and diabetic medications/treatments for this resident. Upon admission, and every 90-days, RN to assess the resident’s ability to self-administer medications. Facility has MD order for the medication, order for self-administration in place, and RN assessment has been completed. 2. HWM and RN will review all resident service plans to ensure they accurately reflect current care needs, service plan was updated to reflect resident's care needs, diagnosis's, current medication regimen and treatments, along with detailed instructions of what to do if any complications arise, who to notify, and when to contact the appropriate parties. 3. HWM will meet with RN and GM weekly to discuss residents of concern, whose needs are changing/increasing, and who needs a change in condition assessment. 4. GM and HWM responsible for seeing corrections are completed, effectively implemented and monitored on an ongoing basis.

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by:

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to determine and document what action or intervention was needed for a resident following a short-term change of condition, document on the progress of the condition at least weekly until resolution, and ensure interventions were communicated to staff on all shifts, for 4 of 6 sampled residents (#s 1, 3, 4, and 5) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 02/2022 with diagnoses including epilepsy. Clinical records, including the current service plan dated 09/27/24, and progress notes from 07/02/24 through 10/01/24 were reviewed, and interviews with the resident and facility staff were conducted during the survey. Resident 5's record was reviewed and the following changes of condition were identified: *On 07/03/24, the resident experienced a non-injury fall in his/her room. There was no documented evidence of resident specific interventions to minimize the further occurrence of falls. *On 07/06/24, the resident experienced a non-injury fall in his/her room. There was no documented evidence of resident specific interventions to minimize the further occurrence of falls. *On 08/05/24, the resident experienced a non-injury fall in his/her room. The incident report noted resident specific interventions to minimize further falls, however, there was no evidence the interventions had been communicated to staff on all shifts. *On 09/06/24, the resident experienced a non-injury fall in his/her room. The incident report noted resident specific interventions to minimize further falls, however, there was no evidence the interventions had been communicated to staff on all shifts. On 10/04/24, the need to ensure changes of condition had resident-specific interventions and were communicated to staff was reviewed with Staff 1 (General Manager) and Staff 2 (Health and Wellness Manager). They acknowledged the findings. 2. Resident 1 was admitted to the facility in 11/2023 with diagnoses including vasomotor rhinitis, chronic atrial fibrillation, sensorineural hearing loss, and presence of cardiac pacemaker. Clinical records, including the current service plan, dated 09/23/24, and progress notes from 07/23/24 through 09/28/24 were reviewed, and interviews with the resident and facility staff were conducted during the survey. The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved: 08/04/24: “very confused”; 08/17/24: new order received for acetaminophen (pain reliever) as needed; 08/29/24: “tube popping off from the catheter bag...”; 08/29/24: “small scabby bumps were noted on R side of catheter…”; 09/14/24: antibiotic prescribed to treat urinary infection was discontinued per family member request; 09/15/24: day shift staff reported increased confusion; 09/17/24: new order for triamcinolone 0.1% ointment for rash; and 09/19/24: new order for doxycycline (anti-infective) for pre-dental visit. The need to ensure the facility determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was reviewed with Staff 1 (General Manager), Staff 2 (Health and Wellness Manager), and Staff 6 (Health and Wellness Nurse) on 10/04/24 at 10:55 am. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 02/2024 with diagnoses including type 2 diabetes mellitus, atrial fibrillation, end stage renal disease, and major depressive disorder. Clinical records, including the current service plan, dated 09/12/24, and progress notes from 07/01/24 through 10/01/24 were reviewed, and interviews with the resident and facility staff were conducted during the survey. The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved: 07/08/24: “L ring finger, is tender…”; 07/10/24: “…L ring finger is red and slightly swelled [sic]”; 07/11/24: “…L ring finger is is [sic] slightly swollen, warm to touch, red in color and painful”; 07/11/24: virtual appointment with legally authorized prescriber and instructions to seek visit at the urgent care; 07/12/24: started new antibiotic for cellulitis; 08/09/24: “S/T [skin tear] on R [right] ankle… site is infected.”; 08/12/24: started on Doxycycline 100mg (anti-infective); 08/13/24: “res stated s/he had lot of burning in his/her chest about 1.5 hours after taking med.”; 08/14/24: “Resident refused… morning dose, for major heart burn...”; 08/15/24: Resident “...refused to take ABX (antibiotic) last 3 doses and refuses to take any longer.”; 08/21/24: vomit and fatigue; 08/25/24: recorded blood sugar levels 539 mg/dl and 555 mg/dl (outside normal parameters); 09/18/24: recorded blood pressure 88/48 mm/Hg (outside normal parameters); 09/20/24: recorded blood sugar level 504 mg/dl (outside normal parameters); 09/21/24: recorded blood sugar level 500 mg/dl (outside normal parameters); and 09/29/24: recorded blood pressure 80/56 mm/Hg (outside normal parameters). The need to ensure the facility determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was reviewed with Staff 1 (General Manager), Staff 2 (Health and Wellness Manager), and Staff 6 (Health and Wellness Nurse) on 10/04/24 at 10:55 am. They acknowledged the findings. 4. Resident 4 was admitted to the facility in 09/2024 with diagnoses including chronic diastolic heart failure, atrial fibrillation, and major depressive disorder. Clinical records, including the current service plan, dated 09/03/24, and progress notes from 09/03/24 through 10/01/24 were reviewed, and interviews with the resident and facility staff were conducted during the survey. The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved: 09/04/24: new move-in; 09/10/24: physician orders “Recommend daily weight…”; 09/21/24: “Looks like there was a small bruise on left upper shoulder.”; and 09/23/24: self-inflicted wounds to left forearm. Resident “admitted that she is ‘struggling and sad’ ”. The need to ensure the facility determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was reviewed with Staff 1 (General Manager) and Staff 6 (Health and Wellness Nurse) on 10/04/24 at 10:10 am. They acknowledged the findings.

OAR 411-054-0040 (1-2) Change in condition and monitoring 1. For resident’s #1, #3, #4, and #5, resident specific interventions were established for short term and significant changes in condition assessments and monitoring. Facility RN will continue to monitor and document weekly at minimum and as needed. 2. Staff have completed training related to observation, reporting, and documentation for monitoring resident changes in conditions. This includes who to report the incident to first, what to monitor for, and when to call EMS. Reportable conditions will trigger incident report and temporary care plans that will be reviewed by HWM, RN, and GM within 24 hours of incident. Temporary care plans will provide resident specific interventions including instructions for staff on what to monitor, who to report to, and facility designee/RN will document the resolution of incident when completely resolved. Staff will ensure the RN is notified on any changes in resident needs. RN will complete COC assessments, monitoring, and service plans updated as needed based on resident specific needs. 3. The GM and HWM/ other designee will review incident reports and significant changes in conditions within 24 hours. Short term monitoring plans will be reviewed daily by HWM/RN to ensure continued compliance. 4. The GM and HWM are responsible for seeing that the corrections are completed, effectively implemented, and monitored appropriately.

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

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed, and written, signed physician or other legally recognized practitioner orders were documented in the resident’s facility record for all medications and treatments that the facility was responsible to administer for 2 of 6 sampled residents (#s 3 and 4) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 02/2024 with diagnoses including type 2 diabetes mellitus, atrial fibrillation, end stage renal disease, and major depressive disorder: Review of Resident 3's current physician orders and MAR from 08/01/24 through 09/30/24 revealed the following: * Metoprolol 25 mg (for heart rate control) was ordered on 08/27/24 to be held for systolic blood pressure less than 120. According to the MAR, systolic blood pressure readings were less than 120 on 15 occasions; however, the medication was not held according to the specified parameters. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (General Manager), Staff 2 (Health and Wellness Manager), and Staff 6 (Health and Wellness Nurse) on 10/04/24 at 10:55 am. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 02/2024 with diagnoses including chronic diastolic heart failure, atrial fibrillation and major depressive disorder. Review of Resident 4's current physician orders, received on 09/11/24, and MAR from 09/03/24 through 09/30/24 revealed the following: a. Metoprolol 25 mg (for heart rate control) 1 tablet was ordered to be held for systolic blood pressure less than 100. According to the MAR, the resident received an incorrect dose of 0.5 tablet on three occasions. Additionally, the MAR also lacked evidence of blood pressure readings on three occasions to determine if the medication needed to be held. b. Physician’s order included “recommend daily weights, call/fax prn 2lb in 2 days weight gain.” According to the MAR, the resident’s weight indicated the following: * 09/19/24: 198 pounds; * 09/20/24: 201 pounds; and * 09/21/24: 208 pounds. On 10/03/04 at 10:40 am an interview with Staff 2 (Health and Wellness Manager), she acknowledged there was no documented evidence the physician was notified of the 10-pound weight gain in two days. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (General Manager) and Staff 6 (Health and Wellness Nurse) on 10/04/24 at 10:10 am. They acknowledged the findings.

OAR 411-054-0055 (1) (f-h) Systems: Treatment Orders 1. Resident #3 and #4 medication and treatment orders have been reviewed and accurately updated to reflect the MAR according to provider instructions, including any parameters (BP, pulse, weight, o2 stats CBGs, medication specifics per MD order), when to notify MD, when to hold medication per order, and resident specific interventions. 3. All new medications and orders to be reviewed by RN and HWM and ensures all medication/treatment orders, instructions, precautions, parameters, and resident specific interventions are entered into MAR and are carried out as prescribed by provider. 4. RN and HWM to conduct MAR audits bi-monthly and quarterly and any needed orders or clarifications will be requested from MD as needed. Third checks on all paperwork received with be done by licensed staff. 5. The GM and HWM/RN are responsible for seeing correction and effectively implemented and monitored.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by:

OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to evaluate a resident's ability to safely self-administer medications and have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications for 3 of 3 sampled residents (#s 1, 2, and 3) who chose to self-administer their medications. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 08/2024 with diagnoses including unspecified glaucoma. Review of Resident 2's 09/01/24 through 10/01/24 MARs noted the following medications for unspecified glaucoma were not administered by the facility: * Latanoprost 0.005% ophthalmic solution, one drop in both eyes every evening; * Dorzolamide HCL solution 2% OP 10 mL, one drop in both eyes twice daily; and * Timolol ophthalmic solution 0.5%, one drop in both eyes twice daily. During an interview on 10/02/24 at 9:40 am, Resident 2 stated s/he managed his/her own eyedrops. The Latanoprost, Dorzolamide, and Timolol were observed in the resident's apartment. There was no documented evidence an evaluation of Resident 2's ability to administer their own medications had been completed. During an interview on 10/02/24 at 11:55 am, Staff 6 (Health and Wellness Nurse) confirmed there was no evaluation completed for self-administration of the medications. Staff 6 completed the quarterly self-administration evaluation on 10/03/24 while the survey team was on site. The lack of the evaluation for self-administration of medications was discussed with Staff 1 (General Manager) and Staff 2 (Health and Wellness Manager) on 10/03/24 at 3:10 pm. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 11/2023 with diagnoses including vasomotor rhinitis, chronic atrial fibrillation, sensorineural hearing loss, and presence of cardiac pacemaker. During the acuity interview on 10/01/24, Resident 1 was not identified as self-administering any of his/her medications. However, review of Resident 1’s MAR on 10/02/24 revealed s/he was self-administering nasal spray, and during the interview on 10/03/24 at 10:40 am with the resident, s/he indicated s/he was administering nasal spray during mealtimes. Review of Resident 1’s medical records revealed there was no documented evaluation of Resident 1's ability to safely self-administer medications, and no physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications was given. In an interview on 10/03/24, Staff 1 (General Manager) and Staff 2 (Health and Wellness Manager) acknowledged no physician or other legally recognized practitioner’s written order or self-administration evaluation was available. The need to ensure residents who chose to self-administer their medications were evaluated upon move-in and at least quarterly thereafter to assure the residents’ ability to safely self-administer medications and had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications was reviewed with Staff 1, Staff 2, and Staff 6 (Health and Wellness Nurse) on 10/04/24 at 10:55 am. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 02/2024 with diagnoses including type 2 diabetes mellitus, atrial fibrillation, end stage renal disease, and major depressive disorder. During the acuity interview on 10/01/24, Resident 3 was identified as self-administering some of his/her medications. During the interview on 10/03/24 at 9:33 am with the resident, s/he indicated s/he was administering pain and supplement medications and insulin subcutaneously. This was confirmed by Staff 10 (Resident Assistant II) in an interview on 10/02/24 and observed by the surveyor on 10/03/24. Review of Resident 3’s medical records revealed there was no documented quarterly evaluation of Resident 3's ability to safely self-administer medications. Staff 6 completed the quarterly self-administration evaluation on 10/03/24 while the survey team was on site. The need to ensure residents who chose to self-administer their medications were evaluated at least quarterly to assure the residents’ ability to safely self-administer medications was reviewed with Staff 1, Staff 2, and Staff 6 on 10/04/24 at 10:55 am. They acknowledged the findings.

OAR 411-054-0055 (5) System: Self-Administration of Meds 1. For residents #1, #2, and #3, order for self-administration, order for medication resident is self-administering, and RN assessment have been complete to ensure resident’s ability to self-administer. 2. RN self-med assessments will be conducted quarterly unless resident experiences a change in condition requiring staff assistance with med management. All orders and RN assessments will be documented and kept in resident charts. 3. RN will conduct quarterly self-med assessments to ensure resident’s ability to self-manage appropriately unless needed due to change in condition. 4. HWM/RN are responsible for ensuring all self-med residents are assessed quarterly. GM and HWM are responsible to ensure correction is effectively implemented and assessments conducted in timely manner.

OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order. This Rule is not met as evidenced by:

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure PRN medications that were given to treat a resident's behavior had resident-specific parameters and non-pharmacological interventions were attempted and documented to be ineffective, prior to their administration for 1 of 2 sampled residents (#6) who were prescribed psychotropic medications. Findings include, but are not limited to: Resident 6 was admitted to the facility in 08/2024 with diagnoses including bipolar disorder. Review of Resident 6's MAR, dated 09/01/24 through 10/01/24, and physician orders revealed the following: a. Resident 6 was prescribed clonazepam 0.5 mg – take one tablet by mouth every 12 hours as needed for anxiety, and it was documented as administered to the resident on sixteen occasions between 09/01/24 and 10/01/24. The facility lacked documented evidence of resident-specific parameters to indicate behaviors for when the medication would be administered and non-pharmacological interventions to attempt prior to administration. In an interview on 10/03/24 at 10:50 am, Staff 10 (Resident Assistant II) confirmed the electronic MAR did not have resident-specific parameters or non-pharmacological interventions listed for staff to attempt prior to administering the PRN medication. b. Resident 6 was prescribed trazodone 0.5 mg – take one tablet by mouth daily at bedtime as needed for insomnia, and it was documented as administered to the resident on two occasions between 09/01/24 and 10/01/24. There was one non-pharmacological intervention to attempt prior to administration, however, it was not documented as ineffective prior to administration of the medication on 09/08/24 and 09/15/24. In an interview on 10/03/24 at 10:52 am, Staff 10 confirmed there was a non-pharmacological intervention to offer Resident 6, but it was not documented as ineffective prior to administration of the medication in the electronic MAR. The need to ensure medications that treat a resident's behaviors had resident-specific parameters and non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of PRN psychotropic medications was discussed with Staff 1 (General Manager) and Staff 2 (Health and Wellness Manager) on 10/03/24 at 3:10 pm. They acknowledged the findings.

OAR 411-054-0055 (6) Systems: Pyschotropic medication 1. For resident #6, all PRN psychotropic medications to treat behaviors have resident-specific parameters and non-pharmacological resident specific interventions prior to the administration of any PRN psychotropic medications. 2. RN will conduct weekly review of all resident’s psychotropic mediations and ensure that all PRN psychotropic have resident specific parameters and non-pharmacological interventions. 3. RN to conduct weekly review of psychotropics to ensure compliance. 4. RN and HWM responsible for seeing correction is effectively implemented and monitored on an ongoing basis.

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

OAR 411-054-0037 (1a)(2-3) Acuity Based Staffing Tool - Elements (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. (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. (b) PROPRIETARY ABST REVIEW REQUEST. If a facility proposes to use a proprietary ABST, the facility must submit the ABST Proprietary Department Review Request (PDRR) Form, including but not limited to the following: (A) All facilities which currently have implemented a proprietary ABST must submit a PDRR Form no later than August 31, 2024. Facilities which do not submit a request on or before August 31, 2024, will be subject to corrective action as outlined in paragraph (9) of this rule. (B) Completed ABST PDRR Form. (C) Sample ABST report displaying all the ABST care elements listed in paragraph (3) of this rule, and the estimated staff time needed to complete each care element, shown per day, in minutes. Although not required, it is preferred that staff time be shown per shift, per day, in minutes. (D) The facility’s ABST policy required under OAR 411-054-0025(7)(i). (c) ABST SUMMARY STATEMENT. If the proprietary review request is approved, a facility must develop and maintain an ABST Summary Statement. The summary statement must be available upon request by the Department. An ABST summary statement must contain a general guide of how the ABST functions, as outlined on the PDRR form. (d) DEPARTMENT REVIEW OF PROPOSED PROPRIETARY ABST REQUEST. The Department will review and either approve or deny the facility’s proprietary ABST. The Department may request additional documentation, potentially including a virtual demonstration, to make the determination. If the ABST is deemed to not meet this rule, the Department may deny or rescind approval at any time. (e) APPEALS PROCESS. The Department will determine whether to approve or deny the request. If the proprietary ABST is denied or rescinded, the facility is entitled to a contested case hearing pursuant to ORS chapter 183. Prior to a contested case hearing, the facility may request an informal conference. (f) ANNUAL STATEMENT. Once approved, the facility must provide the Department an annual statement attesting no substantive changes have occurred to the design of the facility’s proprietary ABST that impacts its functionality. The facility must submit statements to the Department every year, between January 1 and March 31. (g) If the facility makes substantive changes to the design of its proprietary ABST that impacts the ABST’s functionality and if such changes would make the information submitted in support of its approval inaccurate or invalid, the facility must re-submit the ABST PDRR Form as described in this rule to the Department for review prior to implementing the new or revised ABST. (3) ABST CARE ELEMENTS. The required ABST care elements include activities of daily living and other tasks related to resident care and services, as outlined in OAR 411-054-0030, 411-054-0034, and 411-057- 0160. If any individual care element requires more than one staff, additional time must be accounted for as described in 411-054-0070(1). The ABST must individually address and document the care time required to complete each of the following individual ABST care elements: (a) Personal hygiene. (b) Grooming. (c) Dressing and undressing. (d) Toileting, bowel, and bladder management. (e) Bathing. (f) Transfers. (g) Repositioning. (h) Ambulation. (i) Supervising, cueing, or supporting while eating. (j) Medication administration. (k) Providing non-drug interventions for pain management. (l) Providing treatments. (m) Cueing or redirecting due to cognitive impairment or dementia. (n) Ensuring non-drug interventions for behaviors. (o) Assisting with leisure activities, assist with social and recreational activities. (p) Monitoring physical conditions or symptoms. (q) Monitoring behavioral conditions or symptoms. (r) Assisting with communication, assistive devices for hearing, vision, and speech. (s) Responding to call lights. (t) Safety checks, fall prevention (u) Completing resident specific housekeeping or laundry services performed by care staff. (v) Providing additional care services. If additional services are not provided, this element can be omitted. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation. Findings include, but are not limited to: The facility's ABST was reviewed on 10/02/24 at 10:15 am and discussed with Staff 2 (Health and Wellness Manager). She reported the ABST was populated by the service plan for each resident. There was no documented evidence all 22 of the required ADLs were addressed in the tool the facility was using. The need to have all required ADLs on the ABST, and to ensure service plans were reflective so the ABST would be accurate, was discussed with Staff 1 (General Manager) and Staff 2 on 10/03/24 at 3:20 pm. They acknowledged the findings.

OAR 411-054-0037 (1a) (2-3) Acuity Based Staffing Tool - Elements 1. Resident service plans have been updated to reflect appropriate minutes per task and all 22 care elements populating in tool for each. 2. HWC was re-trained by HWM on Eldermark platform and service planning tool related to all services including PRN to ensure all 22 elements populate. 3. HWM and GM to review ABST tool weekly with 1:1 meetings. 4. GM and HWM are responsible to see corrections are effectively implemented and monitored on an ongoing basis.

OAR 411-054-0037 (1a)(2-3) Acuity Based Staffing Tool - Elements (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. (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. (b) PROPRIETARY ABST REVIEW REQUEST. If a facility proposes to use a proprietary ABST, the facility must submit the ABST Proprietary Department Review Request (PDRR) Form, including but not limited to the following: (A) All facilities which currently have implemented a proprietary ABST must submit a PDRR Form no later than August 31, 2024. Facilities which do not submit a request on or before August 31, 2024, will be subject to corrective action as outlined in paragraph (9) of this rule. (B) Completed ABST PDRR Form. (C) Sample ABST report displaying all the ABST care elements listed in paragraph (3) of this rule, and the estimated staff time needed to complete each care element, shown per day, in minutes. Although not required, it is preferred that staff time be shown per shift, per day, in minutes. (D) The facility’s ABST policy required under OAR 411-054-0025(7)(i). (c) ABST SUMMARY STATEMENT. If the proprietary review request is approved, a facility must develop and maintain an ABST Summary Statement. The summary statement must be available upon request by the Department. An ABST summary statement must contain a general guide of how the ABST functions, as outlined on the PDRR form. (d) DEPARTMENT REVIEW OF PROPOSED PROPRIETARY ABST REQUEST. The Department will review and either approve or deny the facility’s proprietary ABST. The Department may request additional documentation, potentially including a virtual demonstration, to make the determination. If the ABST is deemed to not meet this rule, the Department may deny or rescind approval at any time. (e) APPEALS PROCESS. The Department will determine whether to approve or deny the request. If the proprietary ABST is denied or rescinded, the facility is entitled to a contested case hearing pursuant to ORS chapter 183. Prior to a contested case hearing, the facility may request an informal conference. (f) ANNUAL STATEMENT. Once approved, the facility must provide the Department an annual statement attesting no substantive changes have occurred to the design of the facility’s proprietary ABST that impacts its functionality. The facility must submit statements to the Department every year, between January 1 and March 31. (g) If the facility makes substantive changes to the design of its proprietary ABST that impacts the ABST’s functionality and if such changes would make the information submitted in support of its approval inaccurate or invalid, the facility must re-submit the ABST PDRR Form as described in this rule to the Department for review prior to implementing the new or revised ABST. (3) ABST CARE ELEMENTS. The required ABST care elements include activities of daily living and other tasks related to resident care and services, as outlined in OAR 411-054-0030, 411-054-0034, and 411-057- 0160. If any individual care element requires more than one staff, additional time must be accounted for as described in 411-054-0070(1). The ABST must individually address and document the care time required to complete each of the following individual ABST care elements: (a) Personal hygiene. (b) Grooming. (c) Dressing and undressing. (d) Toileting, bowel, and bladder management. (e) Bathing. (f) Transfers. (g) Repositioning. (h) Ambulation. (i) Supervising, cueing, or supporting while eating. (j) Medication administration. (k) Providing non-drug interventions for pain management. (l) Providing treatments. (m) Cueing or redirecting due to cognitive impairment or dementia. (n) Ensuring non-drug interventions for behaviors. (o) Assisting with leisure activities, assist with social and recreational activities. (p) Monitoring physical conditions or symptoms. (q) Monitoring behavioral conditions or symptoms. (r) Assisting with communication, assistive devices for hearing, vision, and speech. (s) Responding to call lights. (t) Safety checks, fall prevention (u) Completing resident specific housekeeping or laundry services performed by care staff. (v) Providing additional care services. If additional services are not provided, this element can be omitted. This Rule is not met as evidenced by:

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to use the results of an ABST to develop and routinely update the facility ' s posted staffing plan, ensure accuracy between the posted staffing plan and ABST, and provide documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. Findings include, but are not limited to: The ABST was reviewed with Staff 2 (Health and Wellness Director) on 02/03/25 and 02/04/25. The facility’s staffing schedule from 01/27/25 through 02/03/25 was reviewed. The following was identified: a. The ABST identified that 19.8 care staff were required to care for residents in a 24 hour period. The facility’s current staffing plan was six care staff on day shift, five care staff on swing shift and two care staff on night shift, for a total of 13 care staff per 24 hour period. In an interview at 9:30 am on 02/04/25, Staff 2 and Staff 26 (General Manager) stated they were not using the results from the ABST to develop the staffing plan as they felt the ABST results did not appear to be accurate. They were unable to provide any additional information regarding why the ABST results were inaccurate or how this was being addressed. b. Upon review of the facility’s staffing schedule, it was identified that 16 of the 16 day or swing shifts were not staffed to meet or exceed the posted staffing plan. The need to use the results of an ABST to develop and routinely update the facility’s posted staffing plan, ensure accuracy between the posted staffing plan and ABST, and provide documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week, was reviewed with Staff 2 and Staff 26 at 3:15 pm on 02/04/25. They acknowledged the findings.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates and Staffing Plan 1. An audit of the Acuity-Based Staffing Tool (ABST) identified inaccuracies in recorded service times and duplicate entries, affecting calculated staffing needs. The Health and Wellness Manager (HWM) and General Manager (GM) reviewed all entries, corrected errors, and ensured staffing levels accurately reflect resident care needs, including unscheduled services. An updated staffing plan has been posted at the front desk 24/7. 2. The corrected ABST data has been used to adjust staffing schedules to match residents' actual care needs, ensuring appropriate caregiver and med tech coverage. A structured review process has been implemented for ongoing accuracy, and care staff have been re-trained on proper service time recording. 3.Moving forward, the HWM will conduct weekly audits of ABST data, making any necessary corrections in a timely manner. The GM and HWM will review ABST and staffing levels weekly at 1:1 meetings to ensure continued compliance with resident care needs. A quarterly review with RN oversight will further support long-term accuracy. The ABST will be review prior to move in's, with any significant changes in condition, and no less than quarterly as a resident's service plans are updated. 4. The GM and HWM are responsible to see that changes are corrected, implemented, and monitored on an ogoing basis.

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 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) 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. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable 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 8, 9, 11, and 13) completed all required pre-service orientation training and 3 of 3 newly-hired direct care staff (#s 8, 11, and 13) completed required pre-service dementia training. Findings include, but are not limited to: Staff training records were reviewed on 10/02/24 with Staff 2 (Health and Wellness Manager) and Staff 4 (Business Office Manager) and the following was identified: a. There was no documented evidence Staff 8 (Resident Assistant II), Staff 9 (Restaurant Server), Staff 11 (Resident Assistant I), or Staff 13 (Resident Assistant I), hired 08/27/24, 08/21/24, 07/18/24, and 08/06/24, respectively, had completed one or more of the following required pre-service orientation topics prior to beginning their job responsibilities: * Infectious disease prevention training; and * Home and Community-Based Services training. b. There was no documented evidence Staff 8, Staff 11 and Staff 13 had completed one or more of the following pre-service dementia care training topics prior to beginning their job responsibilities: * Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to behaviors; reducing use of antipsychotics; * Strategies for addressing social needs and engaging them in meaningful activities; and * Specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach. The need for staff to complete all required pre-service orientation training and for direct care staff to complete required pre-service dementia training was discussed with Staff 1 (General Manager) at 10:10 am on 10/04/24. She acknowledged the findings.

OAR 411-054-0070 (3-4) Staff Requirements and Training - Pre Service 1. Staff #8, #9, #11, #13 have completed pre-service orientation and pre-dementia training, as well as infectious disease prevention training, and HCBS training via Oregon Care Partners. All staff have completed all pre-service trainings and direct care staff have complete pre-service dementia training. 2. All newly hired staff to complete all required pre-service orientation (including HCBS) trainings and direct care staff to complete pre-service dementia training prior to on the floor training. 3. Pre-orientation and pre-service dementia training to be completed before on the floor training and HWM to monitor ongoing required training to ensure compliance. HWM to ensure compliance with scheduled direct care staff. 4. The GM and HWM responsible for ensuring corrections are implemented effectively and all newly hired staff complete all required training before on the floor training.

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) 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. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable 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 29, 30, 31 and 32) completed all required pre-service orientation training and 1 of 1 newly-hired direct care staff (#30) completed required pre-service dementia training. This is a repeat citation. Findings include, but are not limited to: Staff training records were reviewed 02/03/25 through 02/05/25 with Staff 2 (Health and Wellness Manager) and Staff 4 (Business Office Manager) and the following was identified: a. There was no documented evidence Staff 29 (Receptionist), Staff 30 (Resident Assistant I), Staff 31 (Restaurant Server) or Staff 32 (Dishwasher), hired 12/04/24, 12/04/24, 01/08/25 and 01/08/25, respectively, had completed one or more of the following required pre-service orientation topics prior to beginning their job responsibilities: * Infectious disease prevention training; * Home and Community-Based Services training; and * LBGTQIA2S+ training. b. There was no documented evidence Staff 30 had completed the required pre-service dementia training, including all required topics, prior to beginning job responsibilities. The need for staff to complete all required pre-service orientation training and for direct care staff to complete required pre-service dementia training was reviewed on 02/04/25 at 3:15 pm with Staff 2 and Staff 26 (General Manager). They acknowledged the findings.

OAR 411-054-0070 (3-4) Staffing Requirements and Training - Pre-Service 1. Staff #29, #30, #31, and #32 have completed pre-service orientation and dementia training. The General Manager (GM) will ensure that all staff, and any new staff, complete the required pre-service orientation and dementia training per Oregon state regulations prior to any on the floor training, including RELIAS, Oregon Care Partners, and documented compentacies. 2. A review of our training program identified gaps in RELIAS, and the missing courses have since been added to ensure compliance. Additionally, all staff have completed the required Oregon Care Partners trainings, including HCBS and LGBTQIA+ education. 3.With every new hire, all pre-service orientation/ dementia training will be completed prior to training/ working with residents. 4. The GM and HWM are responsible for ensuring corrections are implemented effectively and all newly hired staff complete pre-services trainings before on the floor training.

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) 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. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by:

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired direct care staff (#s 8 and 11) demonstrated competency of skills in all assigned job duties within 30 days of hire and 3 of 3 newly hired staff (#s 8, 11, and 13) were trained in first aid and abdominal thrust. Additionally, it was determined the facility failed to ensure 13 of 14 direct care staff (#s 2, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, and 25) demonstrated knowledge and performance in any duty they were assigned prior to providing care services to residents. The thirteen staff identified to pass medication and provide treatments were working independently and lacked documentation of competency in medication administration, which put residents for which they administered medications at risk for serious harm. Findings include, but are not limited to: Employee training records were reviewed on 10/02/24 at 1:15 pm with Staff 2 (Health and Wellness Manager) and revealed the following: a. Staff 8 (Resident Assistant II), hired on 08/27/24, was identified on the staff list as a Resident Assistant II, the facility’s equivalent to a medication technician. During an interview at 1:15 pm on 10/02/24, Staff 2 clarified Staff 8 was not currently working as a MT and her job title was Resident Assistant I. The surveyor requested documented evidence of the facility’s process for determining competency in medication administration for another newly hired staff, Staff 15 (Resident Assistant II), hired on 04/12/24. During an interview on 10/02/24 at 2:15 pm, Staff 2 acknowledged the facility did not have a process to document competency for medication administration for providing medications and treatments. She stated they had switched from paper records to all electronic documentation and those classes and ability to document observations were not included. At request of the surveyor, Staff 2 identified fourteen staff who had been working in the facility independently as a MT, which included administering medications and treatments to residents. During an interview on 10/02/24 at 2:35 pm, Staff 20 (Resident Assistant II) indicated she “shadowed [a MT] five days and then they said I was good to go.” She did not recall any paperwork regarding competency in “med passing and MT duties.” During an interview on 10/02/24 at 2:45 pm, Staff 22 (Resident Assistant II) reported she was trained by “shadowing others for a few days and then I was on my own.” When she was checked off on being independent “I was only asked how I felt about the training and if there was anything I want more training in.” The following staff lacked documented evidence of competency for med pass: * Staff 2, hired 10/24/13; * Staff 14 (Resident Assistant II), hired 12/13/21; * Staff 15 (Resident Assistant II), hired 04/12/24; * Staff 16 (Resident Assistant II), hired 10/10/16; * Staff 17 (Resident Assistant II), hired 05/21/16; * Staff 18 (Resident Assistant II), hired 07/24/23; * Staff 19 (Health and Wellness Coordinator), hired 11/03/23; * Staff 20 (Resident Assistant II), hired 07/26/23; * Staff 21 (Resident Assistant II), hired 05/09/19; * Staff 22 (Resident Assistant II), hired 10/22/18; * Staff 23 (Resident Assistant II), hired 06/26/12; * Staff 24 (Resident Assistant II), hired 03/18/22; and * Staff 25 (Resident Assistant II), hired 03/30/23. On 10/02/24 at 4:00 pm, the survey team requested an immediate plan of correction (POC) to ensure Resident Assistant II/MTs, whose job it was to administer medications to residents, were trained by appropriate facility staff and there was documentation to show they had observed and evaluated the MT's ability to perform safe medication administration unsupervised. On 10/02/24 at approximately 5:05 pm, the facility submitted a POC that was accepted by the survey team. Staff 2 located her competencies from 10/2015, provided the documented evidence, and was involved in observing competencies for the additional staff on the immediate upcoming shifts. Staff 6 (Health and Wellness Nurse) completed the competency for the MT who was currently working swing shift. The facility identified a scheduled plan to evaluate and document competency for the remaining staff on the next shifts they were scheduled and prior to them administering medications unsupervised. The immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violation. The need to ensure the facility had documented evidence of MT demonstrating competencies prior to performing medication and treatment administration was discussed with Staff 1 (General Manager) and Staff 6 on 10/04/24 at 10:10 am. They acknowledged the findings. b. Staff 8 (Resident Assistant II), hired on 08/27/24, and Staff 11 (Resident Assistant I), hired on 07/18/24, lacked documented evidence of competency within 30 days of hire in the following required topics: * Role of service plans in providing individualized care; * Changes associated with normal aging; and * Identification, documentation, and reporting changes of condition. c. Staff 8, Staff 11, and Staff 13 (Resident Assistant I), hired on 08/06/24, lacked documented evidence they had completed first aid and abdominal thrust training within 30 days of hire. The need to ensure staff had documented evidence of competency demonstration within 30 days of hire and completion of first aid and abdominal thrust training, was discussed with Staff 1 (General Manager) and Staff 6 on 10/04/24 at 10:10 am. They acknowledged the findings. .

OAR 411-054-0070 (5 & 9-10) Training within 30 days of hire - direct care staff 1. All direct care staff have been evaluated/observed by HWM/RN to ensure required trainings/competencies for RAII and RAI’s and physical documentation kept in employee file after demostrating satisfactory performace. BLS/CPR was obtained for all staff and RN providing abdominal thrust training for direct care staff and documentation completed. (Staff #2, 14, 15, 16, 17, 18, 19, 20, 22, 23, 24, and 25). 2. HWM and BOM to track/audit new hires for required documentation in the first week and 30 days. Any new RAIIs to train a minimum of 5 days with lead RAII’s and HWM/RN to observe/eval post-training completion before administering medication or treatments unsupervised. Competencies documented and kept in employee file. 3. HWM and BOM to track/audit new hires for required documentation in the first week and 30 days. 4. GM and HWM are responsible for ensuring all staff competencies are completed for all staff within 30 days - corrections are completed, implemented, and documented appropriately.

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by:

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to conduct unannounced fire drills according to the Oregon Fire Code (OFC) and failed to provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to: a. Fire drill records from 04/2024 through 08/2024 were reviewed with Staff 3 (Plant Operations Supervisor) on 10/02/24. Fire drill records lacked documentation that the following required elements were consistently followed: * Escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; * Evacuation time period needed; * Number of occupants evacuated; and * Evidence alternate routes were used during fire drills. b. There was no documented evidence the facility provided fire and life safety training consistently to staff on alternate months. The need to ensure the facility conducted unannounced fire drills according to the OFC and provided fire and life safety instruction to staff on alternate months was discussed with Staff 1 (General Manager) at 10:10 am on 10/04/24. She acknowledged the findings. No further information was provided.

OAR- 411-054-0090 (1-2) Fire and Life Safety 1. Plant Ops Supervisor to ensure proper documention with each unannouced fire drill according to OFC. Documentation to include escape route used, any problems encountered, evacuation time period needed, number of occupants evacuated, and documentation/evidence that alternate routes used during fire drills. Instruction given to staff and residents on general safety procedures, evacuation methods, responsibilities during drills and where designated meeting places are inside and outside the building. 2. Fire drills to be conducted on alternating months on each shift and documented appropriately. Instructions to staff and residents on safety procedures, evacuation methods, responsibilties during drills, and where designated meeting areas are inside/outside building. 3. Alternating Months 4. GM and Plant Ops responsible for seeing corrections are completed, effectively implemented, and documented appropriately.

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 411-054-0105 (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: Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 370.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval 1. To address the deficiency identified during the re-licensure survey, the General Manager (GM) and Health & Wellness Manager (HWM) will ensure all pre-service training is completed by both current and new staff in accordance with Oregon state requirements. This includes mandatory training such as Dementia Care through Oregon Care Partners, Pre-Service Orientation covering resident rights, abuse prevention, infection control, emergency procedures, HCBS, and LGBTQIAS+ training. All new hires will be required to complete these trainings before working on the floor. 2. To maintain compliance, the GM and HWM will ensure all new staff complete pre-service trainings prior to their first shift. GM and HWM conduct internal audits and review training completion during annual staff evaluations. Any staff member found non-compliant with training requirements will be removed from the schedule until training is completed. The GM and HWM will also maintain training log with completion dates, certificates, and staff signatures, ensuring documentation is readily available for OR DHS review. 3. GM and HWM will ensure all pre-service trainings are completed by new-staff prior to working the floor. GM and HWM to conduct quarterly audits of exisiting staff to ensure annual trainings are completed to ensure compliance. 4. The GM is responsible for ensuring corrections are made, implemented effectively, and all new staff completed all required pre-service trainings prior to working on the floor.

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:

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF 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) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF 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 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF 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 did not contain drop offs to prevent tripping hazards for residents. Findings include, but are not limited to: The exterior of the facility was toured on 10/01/24 and 10/02/24. Exterior pathways throughout the facility campus and courtyard contained drop-offs up to approximately two and a half inches, measured from the edge of a concrete sidewalk to the edge of the planter. These drop-offs created potential fall hazards for residents. On 10/02/24, the building's exterior was toured with Staff 1 (General Manager) and Staff 3 (Plant Operations Supervisor). They acknowledged the findings.

OAR 411-054-0300 (3) (a-h) General Building exterior 1. Plant Ops supervisor filled all drop-offs to prevent fall hazards. 2. Plant Ops supervisor to ensure all drop offs are at required level (Two and half inches measured from the edge of the concrete sidewalk to the edge of the planter). 3. Plant Ops Supervisor to conduct weekly checks to ensure drop offs are even with the sidewalks. 4. Plant Ops and GM to ensure the is completed and effectively implemented.

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF 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) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF 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 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF 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 411-054-0300 (5) Resident Units (5) RESIDENT UNITS. All resident units must be accessible per building codes. These apartments must have a lockable entry door with lever type handle, a private bathroom, and kitchenette facilities. Adaptable units are not acceptable.(a) UNIT DIMENSIONS. New construction units must have a minimum of 220 net square feet, not including the bathroom. Units in pre-existing structures being remodeled must have a minimum of 160 square feet, not including the bathroom.(b) RESIDENT STORAGE SPACE.(A) Each unit must provide usable space totaling at least 100 cubic feet for resident clothing and belongings and include one clothes closet with a minimum of four linear feet of hanging space.(B) The rod must be adjustable for reach ranges per building codes. In calculating useable space, closet height may not exceed eight feet and a depth of two feet.(C) Kitchen cabinets must not be included when measuring storage space.(D) A lockable storage space (e.g., drawer, cabinet, or closet) must be provided for the safekeeping of a resident ' s small valuable items and funds. Both the administrator and resident may have keys.(c) WINDOWS.(A) Each resident's living room and bedroom must have an exterior window that has an area at least one-tenth of the floor area of the room.(B) Unit windows must be equipped with curtains or blinds for privacy and control of sunlight.(C) Operable windows must be designed to prevent accidental falls when sill heights are lower than 36 inches and above the first floor.(d) DOORS. Each unit must have an entry door that does not swing into the exit corridor.(A) A locking device must be included that is released with action of the inside lever. Locks for the entry door must be individually keyed, master keyed, and a key supplied to the resident.(B) The unit exit door must open to an indoor, temperature controlled, common-use area or common corridor.(e) BATHROOM. The unit bathroom must be a separate room with a toilet, sink, a roll-in curbless shower, towel bar, toilet paper holder, mirror, and storage for toiletry items.(A) The door to the bathroom must open outward or slide into the wall.(B) Showers must have a slip-resistant floor surface in front of roll-in showers, a hand-held showerhead, cleanable shower curtains, and appropriate grab bar.(f) KITCHENS OR KITCHENETTES. Each unit must have a kitchen area equipped with the following:(A) A sink, refrigerator, and cooking appliance that may be removed or disconnected. A microwave is considered a cooking appliance.(B) Adequate space for food preparation.(C) Storage space for utensils and supplies.(D) Counter heights may not be higher than 34 inches. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. Findings include, but are not limited to: On 10/02/24, the facility interior was toured. Multiple vertically and horizontally opening windows in resident rooms on the second floor, with windowsills lower than 36 inches from the floor, lacked a system which limited how far the window could be opened to prevent accidental falls. On 10/02/24, the lack of a mechanism to prevent accidental falls from upper floor windows was discussed with Staff 1 (General Manager) and Staff 3 (Plant Operations Supervisor). They acknowledged the findings.