OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure injuries of unknown cause and allegations of abuse were promptly investigated to rule out abuse and/or reported to the local SPD office when required, for 2 of 3 sampled residents (#s 1 and 2) reviewed with incidents. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 04/2020 with diagnoses including dementia and seizures. Observations of the resident, interviews with staff, and review of the resident's 07/21/24 service plan, 07/01/24 through 10/07/24 temporary service plans, progress notes, physician communications, and incident investigations were completed. The resident was able to communicate needs to staff and required full assistance of one staff for ADL care and transfers. The resident was forgetful and did not fully recognize his/her limitations and had poor safety awareness. The resident could move his/her wheelchair around the facility at will. The resident was identified as having fragile skin. Review of the resident's records showed the following: * A progress note dated 07/03/24 indicated the resident had a small bruise to the knuckle of the right hand. The resident did not know how it had occurred. No investigation was documented regarding the bruise. * A progress note dated 09/25/24, indicated the resident told staff, “A long time ago, someone hit (him/her) on the nose purposefully while caring for (him/her).” The resident was unable to provide any other information. There was no additional information within the progress notes about the bruise or the allegation of abuse, related to what occurred, how abuse and neglect was ruled out, the staff response to the resident incidents, and follow-up action related to the incidents. The facility was asked to report both incidents to the local SPD office. A confirmation of the reports was provided to the surveyor. The need to ensure all incidents were promptly investigated to rule out abuse was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 3 (Administrative Assistant) on 10/08/24 and 10/9/24. The staff acknowledged the findings. 2. Resident 2 was admitted to the facility in 04/2024 with diagnoses including dementia and hip fracture. Observations of the resident, interviews with staff, and review of the resident's 10/01/24 service plan, 07/01/24 through 10/07/24 temporary service plans, progress notes, physician communications, and incident investigations were completed. The resident was able to communicate needs to staff and was able to complete most of his/her ADLs without assistance. Staff intermittently assisted the resident with hygiene and incontinent care when requested. The resident spent most of his/her time in his/her apartment. The resident came out for meals and took himself/herself to the restroom. The resident primarily used a wheelchair to get around the facility because of hip and back fractures. Review of the resident’s records showed the following: * A progress note dated 09/02/24 indicated a caregiver was “too rough and in a hurry, with too much damn energy” and “ripped (his/her) shirt over (his/her) head.” The resident indicated this was how the scab on his/her head came off which caused the resident’s head to bleed. There was no additional information within the progress notes about the allegation of abuse related to what occurred, how abuse and neglect were ruled out, the staff response to the resident incidents, and follow-up action related to the incidents. The facility was asked to report the incident to the local SPD office. A confirmation of the report was provided to the surveyor. The need to ensure all incidents were promptly investigated to rule out abuse and/or neglect was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (Administrative Assistant) on 10/08/24 and 10/9/24. The staff acknowledged the findings.

1.) All incidents from the samples pulled have been reported and turned into Adult Protective Services for investigation. Confirmations were turned in to the surveyor. 2.) The Administration team and facility RN will review OAR 411-054-0028 (Reporting and Investigating Abuse and Other Actions Reflecting Resident Welfare). After reviewing incident reports and skin assessments, the Administrator and facility RN will report allegations of abuse to Adult Protective Services regarding bruising, skin tears and other injuries of unknown cause as well as resident reported abuse after our internal investigation is completed and abuse and neglect cannot be ruled out. 3.) Injuries, skin impairments and allegations of abuse or neglect will be immediately reported by staff to the administrator and/or facility RN. After the administrator and/or facility RN performs the investigation of the reported injury, impairment or allegation; if unable to rule out abuse and neglect, the Administrator and/or facility RN will call and/or email Adult Protective Services within 24 hours to report the reported incident. Local law enforcement will be notified of possible abuse/neglect if the abuse appears to be a crime. 4.) The Administrator and facility RN will be responsible for compliance.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by:

OAR 411-054-0036 (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' needs, provided clear direction to staff regarding care and services, and were consistently implemented by staff for 3 of 5 sampled residents (#s 1, 2, and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 04/2020 with diagnoses including dementia and seizures. Observations of the resident, interviews with staff and review of the service plan, dated 07/21/24, showed the service plan was not reflective of the resident's current care needs, was inconsistently implemented, and/or did not provide clear direction to staff in the following areas: * Chronic wound and fragile skin; * Toileting frequency; * Perineal care and incontinent care assistance; * Meal reminders for swallowing precautions; * Behaviors, resistance to care; * Non-drug interventions for chronic pain; * Stoma care responsibilities and process; and * Air overlay operation. The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (Administrative Assistant) on 10/09/24. The staff acknowledged the findings. 2. Resident 2 was admitted to the facility in 04/2024 with diagnoses including dementia and seizures. Observations of the resident, interviews with staff, and review of the service plan, dated 10/01/24, showed the service plan was not reflective of the resident's current care needs, was inconsistently implemented, and/or did not provide clear direction to staff in the following areas: * Grooming and hygiene assistance; * Toileting, perineal care, and incontinent care assistance; * History of choking with Heimlich needed; * Meal reminders including eating slowly; * Contractures, stretches, and exercise program; * Meal reminders for swallowing precautions; * Behaviors, resistance to care; and * Non-drug interventions for pain. The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (Administrative Assistant) on 10/09/24. The staff acknowledged the findings. 3. Resident 5 was admitted to the facility in 12/2022 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the service plan, dated 09/22/24, showed the service plan was not reflective of the resident's current care needs, was inconsistently implemented, and/or did not provide clear direction to staff in the following areas: * Use of glasses; * Activities and interventions when up during the night; * Toileting frequency, perineal care, and incontinent care assistance; * Behaviors, including resistance to care; * Non-drug interventions for pain; * Safety interventions and resident compliance level; * Hallucinations, delusions, accusations; and * Diet texture and meal observation. The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (Administrative Assistant) on 10/09/24. The staff acknowledged the findings.

1.) The residents' service plans that were pulled have been updated and reflect the residents' needs, their preferences and provide clear direction to staff. 2.) The service planing team (administration staff, facility RN and care staff) will review the service plans on admission, 30 days after admission, quarterly and change of condition. The service plans will be updated to be resident centered and provide clear direction to staff. 3.) Before move in, 30 days after admission, quarterly and change of condition. 4.) The service planning team will be responsible for correction. The Administrator will be responsible for compliance.

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 ensure residents who had short-term changes of condition were evaluated, were referred to the facility RN when indicated, resident-specific instructions or interventions were developed and reviewed for effectiveness, and weekly progress documented until resolution for 4 of 5 sampled residents (#s 1, 2, 3 and 5) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 04/2020 with diagnoses including dementia and seizures. Observations of the resident, interviews with staff, and review of the resident's 07/21/24 service plan, 07/01/24 through 10/07/24 temporary service plans, progress notes, physician communications, and incident investigations were completed. The resident experienced multiple short-term changes without noted progress at least weekly until resolved and/or lacked resident-specific directions to staff in the following areas: * Bruises; * Medication changes; * Allegation of resident altercation/abuse; * Blood-tinged sputum from ostomy; and * Sore on the buttocks. The need to ensure short-term changes of condition had documentation of weekly progress until resolution, interventions were re-evaluated for effectiveness, and clear, resident-specific directions were provided to staff was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (Administrative Assistant) on 10/09/24. The staff acknowledged the findings. 2. Resident 2 was admitted to the facility in 04/2024 with diagnoses including dementia and hip fracture. Observations of the resident, interviews with staff, and review of the resident's 10/01/24 service plan, and 07/01/24 through 10/07/24 temporary service plans, progress notes, physician communications, and incident investigations were completed. The resident experienced multiple short-term changes without noted progress at least weekly until resolved and/or lacked resident-specific directions to staff in the following areas: * Behaviors and agitation; * Medication changes; * Allegation of resident altercation/abuse; and * Staple removal. The need to ensure short-term changes of condition had documentation of weekly progress until resolution, interventions were re-evaluated for effectiveness and clear, resident-specific directions were provided to staff was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (Administrative Assistant) on 10/09/24. The staff acknowledged the findings. 3. Resident 5 was admitted to the facility in 12/2022 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's 09/22/24 service plan, 07/10/24 through 10/03/24 temporary service plans, progress notes, physician communications, and incident investigations were completed. The resident experienced multiple short-term changes without noted progress at least weekly until resolved and/or lacked resident-specific directions to staff in the following areas: * COVID positive; * Injury and non-injury falls; * ER returns; * Medication changes; * Vomiting; * Urinary tract infection and antibiotic use; and * Elbow fracture and skin tears. The need to ensure short-term changes of condition had documentation of weekly progress until resolution, interventions were re-evaluated for effectiveness, and clear, resident-specific directions were provided to staff was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (Administrative Assistant) on 10/09/24. The staff acknowledged the findings. 4. Resident 3 was admitted to the facility in 05/2019 with diagnoses including Alzheimer’s disease and pica. The resident’s 08/23/24 service plan, 07/09/24 through 10/03/24 progress notes, temporary service plans, and weight and meal intake records were reviewed, and staff were interviewed. The following was identified: * 06/2024 – Resident weighed 110 pounds; and * 07/2024 – Resident weighed 102 pounds. Resident 3 experienced a weight loss of 8 pounds, or 7.27% of his/her total body weight, in 30 days. This constituted a severe weight loss and a significant change of condition. In an interview on 10/09/24, Staff 2 (RN) reported caregivers weighed residents, entered the weights into the eMAR, and she reviewed them weekly. She indicated staff did not usually inform her when residents had lost a significant amount of weight. The need to ensure the facility RN was informed of significant changes of condition was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 10/09/24 at 2:00 pm. They acknowledged the findings.

1.) Service plans from samples pulled have been updated to reflext the most recent changes and easily readable directions for staff as well what is to be being monitored for the resident. Incident reports completed and sent to APS, surveys notified. 2.) Re-education provided to Med Techs and caregivers in regard to community alert charting and temporary service plans. Facility RN will ensure that weekly progress notes are completed on residents that are being monitored. Administration team and facility RN will assure routine audits of resident care related documentation. 3.) Audits will be done daily/weekly. 4.) Facility RN and Administrator will be responsible for compliance.

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

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed in a timely manner, which documented findings, resident status, and interventions made as a result of the assessment for 3 of 3 sampled residents (#s 2, 3, and 5) who experienced significant changes of condition. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 04/2024 with diagnoses including failure to thrive and dementia. Observations of the resident, interviews with staff, and review of the resident's 10/01/24 service plan and 07/01/24 through 10/07/24 temporary service plans, progress notes, physician communications, and incident investigations were completed. The resident required intermittent assistance from staff for ADL care. The resident frequently refused meals if agitated but would accept a health shake in its place. The resident was able to make some needs known but was very independent and had poor safety awareness. The resident came out of his/her room only for meals and to use the restroom and spent the majority of his/her time in his/her room. Multiple observations of the resident between 10/07/24 and10/09/24 showed the resident in his/her room with the door closed. The resident came out for meals when staff told him/her the meal was ready. The resident brought himself/herself to the table, ate quickly and returned to his/her apartment. The resident completed his/her own transfers and toileting without seeking staff assistance. a. The resident experienced a fall on 08/01/24 with pain. The resident was sent out to the emergency room for evaluation and admitted for surgical repair of a left hip fracture. b. The resident had a choking episode with the Heimlich maneuver performed, on 08/11/24, and was sent out to the hospital for evaluation. The resident was found to have an L4 and L5 spinal fracture suspected as a result of the Heimlich maneuver. The resident had a history of previous spinal injuries, it was not determined if the currently diagnosed spinal fractures were an old or new injury. In interviews between 10/07/24 and 10/08/24, the resident indicated s/he had no concerns and had plenty to eat and drink. The resident stated s/he ate when s/he wanted to eat. The resident indicated his/her pain was the same as always and did not feel the fractures had affected much but his/her walking. In interviews between 10/07/24 and 10/08/24, Staff 8 (CG) and Staff 11 (MT) indicated the resident was independent with meals. The resident would become irritated if s/he had to wait too long, so staff notified him/her when food was coming out of the kitchen. Staff 11 stated if the resident had to wait s/he would become irritated, leave the table, and refuse the meal. The staff indicated the resident completed most ADLs on his/her own. The staff attempted to offer help and ensure the resident was well cleaned between incontinent episodes when the resident would allow. Staff 11 indicated the resident was very independent and wanted to do things his/her own way. In interview on 10/09/24, Staff 2 (RN) indicated she was concerned about weight loss when the resident came back from the hospital and had put the resident on weekly weights as well as trying to get the resident’s appetite stimulant back on the orders. Staff 2 further indicated she did an assessment on 08/05/24 that discussed the resident’s weight loss and that the resident had experienced a hip fracture. Staff 2 did not document an additional assessment regarding the back fractures. She did not have any additional documentation regarding changes in the resident’s ADL needs or interventions implemented for the fractures. The facility failed to ensure an RN assessment was completed in a timely manner for weight loss, hip fracture, and a back fracture, which documented findings, resident status, and interventions made as a result of the assessment. The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made as a result of the assessment, was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 10/09/24. The staff acknowledged the findings. 2. Resident 5 was admitted to the facility in 12/2022 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's 09/22/24 service plan, 07/10/24 through 10/03/24 temporary service plans, progress notes, physician communications, and incident investigations were completed. The resident required intermittent assistance from staff for ADL care. The resident was able to eat independently with some reminders to chew and swallow slowly. The resident preferred to stay in their apartment but would typically attend all three meals in the dining room. The resident was able to make some needs known but was very independent and did not always make safe choices. Multiple observations of the resident between 10/07/24 and10/09/24 showed the resident in his/her room with the door closed. The resident came out for meals when staff told him/her the meal was ready. The resident brought himself/herself to the table with his/her walker, ate, and then would return to his/her apartment. The staff attempted to keep the resident’s door open for safety, but the resident would get up and close the door. The resident frequently completed ADLs on his/her own without requesting staff assistance. Staff attempted to help as often as they could get the resident to accept. The resident experienced a fall on 08/27/24 resulting in right arm pain. The resident was sent out to the emergency room for evaluation and found to have a right elbow fracture. In interviews between 10/07/24 and 10/08/24, the resident indicated s/he had no concerns. S/he could take care of things that s/he needed and ask for help as s/he needed it. The resident indicated pain was okay at this time. In interview on 10/09/24, Staff 2 (RN) indicated she did not notice a big change for the resident when his/her elbow was fractured. Staff 2 stated she could have documented a more thorough assessment of the fracture. She did not have any additional documentation regarding changes in the resident’s ADL needs or interventions implemented. The facility failed to ensure an RN assessment was completed for an elbow fracture, which documented findings, resident status, and interventions made as a result of the assessment. The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 10/09/24. The staff acknowledged the findings. 3. Resident 3 was admitted to the facility in 05/2019 with diagnoses including Alzheimer’s disease and pica. The resident’s 08/23/24 service plan, 07/09/24 through 10/03/24 progress notes, temporary service plans, and weight and meal intake records were reviewed, and staff were interviewed. The following was identified: *06/2024 – Resident weighed 110 pounds; and *07/2024 – Resident weighed 102 pounds. Resident 3 experienced a weight loss of 8 pounds, or 7.27% of his/her total body weight, in 30 days. This constituted a severe weight loss and a significant change of condition. The resident was admitted to hospice services on 07/22/24. On 07/25/24 Staff 2 (RN) made a “Late entry for 7/22/24” noting the resident was admitted to hospice for “’end of life care.” Staff 2 also noted “[S/he] continues to have … weight loss although appears to be eating adequate amount . . .” She further noted the resident had a history of cancer and the resident’s family did not wish to pursue treatment but wanted to make him/her comfortable for end-of-life care. The resident’s service plan identified the resident was on a puree diet and drank “regular fluids/foods from a cup” and s/he received a “house shake with a snack 3 x daily.” Interviews with staff during the survey indicated the resident was given fluids and pureed food in a “sippy cup,” which s/he was able to hold themselves “most of the time.” Staff indicated they sometimes fed the resident yogurt or applesauce. During the survey, the resident was observed on multiple occasions to be holding and drinking from a “sippy cup.” Meal intake records revealed the resident’s intake was consistently 100% of each meal. Between 07/09/24 and 10/09/24, of the 189 meals documented there were 14 occasions on which s/he did not eat 100%. The resident’s 09/01/24 through 10/07/24 MARs revealed the resident received health shakes and snacks three times a day. In an interview on 10/09/24, Staff 2 (RN) reported caregivers weighed residents, entered the weights into the eMAR, and she reviewed them weekly. She indicated staff do not usually inform her when residents lose weight. She stated she discovered the resident’s eight-pound weight loss on 07/16/24 and had him/her admitted to hospice on 07/22/24. The need to ensure the facility RN assessed all significant changes of condition, including findings, resident status, and interventions made as a result of the assessment, in a timely manner was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 10/09/24 at 2:00 pm. They acknowledged the findings.

1.) Service plans from samples pulled have been updated to reflext the most recent changes and easily readable directions for staff as well what is to be being monitored for the resident. Incident reports completed and sent to APS, surveys notified. 2.) Re-education provided to Med Techs and caregivers in regard to community alert charting and temporary service plans. Facility RN will ensure that weekly progress notes are completed on residents that are being monitored. Administration team and facility RN will assure routine audits of resident care related documentation. 3.) Audits will be done daily/weekly. 4.) Facility RN and Administrator will be responsible for compliance.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 4 sampled residents (#1) whose MARs and Controlled Substance Disposition logs were reviewed. Findings include, but are not limited to: Resident 1 was admitted to the facility in 04/2020 with diagnoses including dementia and seizures. Observations of the resident, interviews with staff, and record review were completed. The resident’s signed physician orders were dated 08/21/24 and showed the following: * Hydrocodone-APAP 5-325 mg tablet, take one tablet PRN every four hours for severe pain. The resident's Controlled Substance Disposition logs and MARS dated 09/01/24 through 10/07/24, and observation of the medication cards on 10/09/24, showed the following: * On 10/07/23 PRN Hydrocodone was recorded on the MAR at 7:56 am and recorded on the disposition log at 7:21 pm; * The medication cards did not reflect the current physician order for the administration of the medication; and * Comparison of the medication cards and the disposition log showed each of the two active cards had one less pill than indicated on the disposition log. In an interview on 10/09/24, Staff 18 (MT) indicated the resident’s pain medication orders had changed a couple times recently and new labels were not in place. Staff 18 indicated if he needed to give the resident his/her PRN pain medication he would punch from the card already in use, marked bedtime. Staff 18 had no information on why the count recorded in the disposition log did not match the card. In an interview on 10/09/24, Staff 1 (Administrator) and Staff 2 (RN) indicated new labels should have been applied to the resident’s medication cards. The orders had changed several times between scheduled and PRN. They were unaware of an inaccurate narcotic count. Staff 2 stated she would complete an investigation/incident report regarding the discrepancy. No additional information was provided regarding the medication discrepancies. The need to ensure narcotic disposition logs, MARs, and medication cards accurately reflected medication administered was discussed with Staff 1 and Staff 2 on 10/09/24. The staff acknowledged the findings.

1.) Resident 1 narcatic log reviewed and corrected. Staff education provided. Change in order stickers available to the staff. Staff directed on use. 2.) Narcatic books and resident MAR will be audited by Administration team and/or facility RN. 3.) Daily/Weekly 4.) Administrative team and facility RN will be responsible for compliance.

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by:

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, included medication-specific instructions, and had specific parameters for PRN medications for 4 of 5 sampled residents (#s 1, 2, 3, and 5) whose MARs were reviewed. Findings include, but are not limited to: 1.Resident 3 was admitted to the facility in 05/2019 with diagnoses including Alzheimer’s disease and pica. The resident’s 09/01/24 through 10/07/24 MARs and physician orders were reviewed. The following was identified: *The resident had physician orders for Milk of Magnesia, bisacodyl suppository, and phosphate enema, all PRN for bowel care. There were no parameters for staff to determine the order of administration. *The resident had two as-needed prescriptions for pain, including acetaminophen and morphine sulfate. There were no parameters instructing staff on the order of administration. The need to ensure there were parameters in place for multiple PRN medications for the same purpose was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 10/09/24. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 04/2020 with diagnoses including dementia. The resident's 07/01/24 through 10/07/24 progress notes and physician communications, 08/21/24 signed physician orders, and the 09/01/24 through 10/07/24 MARs/TARs were reviewed and showed the following: * Tylenol 8am dose was not given 09/20/24 through 09/25/24 with reasons noted as prior authorization needed, outside parameters and not arrived. The medication did not have parameters in place, did not require a prior authorization and a house stock was available in the facility. Staff 1 (Administrator) and Staff 2 (RN) were unsure why staff marked the medication as not given with the reasons selected as the medication was available in the house supply in the facility. * The 09/24/24 Amlodipine and 09/24/24 Losartan both for high blood pressure, were held with a note that stated, “outside of parameters.” No vital signs were recorded to show the resident’s blood pressure or pulse were outside the hold parameters ordered by the physician; * A house shake was ordered for the resident four times a day. The shake was frequently circled as not given with reasons noted as refused and out of stock, multiple times within the same day; * Tracheostomy stoma cleaning lacked information for staff on the full process; * Tylenol and Hydrocodone were both ordered PRN for pain, there was no direction for staff on which medication to use first and when; and * Resident specific directions for staff were not documented for the use of Narcan, for opioid overdose reversal. The need to ensure medication administration records were complete was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 3 (Administrative Assistant) on 10/09/24. The staff acknowledged the findings. 3. Resident 2 was admitted to the facility in 04/2024 with diagnoses including dementia. The resident's 07/01/24 through 10/07/24 progress notes and physician communications, 08/15/24 signed physician orders, and the 09/01/24 through 10/07/24 MARs/TARs were reviewed and showed the following: * Tylenol ordered three times a day was circled as not given for the mid-day dose on 09/01/24 and 09/02/24, reason documented as not arrived from pharmacy. The morning and evening doses were given as ordered: * Mirtazapine ordered daily at bedtime to help stimulate appetite, was circled as not given from 09/06/24 to 09/19/24, reason documented as not arrived from pharmacy or prior authorization needed. The doses prior to 09/06/24 and after 09/19/24 were given as ordered with no additional documentation as to why medication would have run out mid-week/mid-month or other follow up; * Tylenol and Hydrocodone were both ordered PRN for pain, there was no direction for staff on which medication to use first and when; * Senna, ordered PRN for constipation had no resident specific directions for staff on when to start the medication; and * Blanks were noted on the MAR related to weekly weight tracking; The need to ensure medication administration records were complete was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 3 (Administrative Assistant) on 10/09/24. The staff acknowledged the findings. 4. Resident 5 was admitted to the facility in 04/2024 with diagnoses including dementia. The resident's 07/10/24 through 10/03/24 progress notes and physician communications, 09/09/24 signed physician orders, and the 09/01/24 through 10/07/24 MARs/TARs were reviewed and showed the following: * Rexulti ordered daily for dementia was circled as not given on 09/12/24, 09/13/24 and 09/16/24, reason documented as not arrived from pharmacy. All other daily doses were signed as administered including 09/14/24 and 09/15/24; * Bisacodyl suppository, Senna and Milk of Magnesia ordered PRN for constipation, there were no resident specific parameters to determine when to use which medication; * Tums ordered PRN for heart burn, indicated chew 1-4 tablets PRN, there was no resident specific parameters for staff to determine how many tablets to give the resident and when; and * Hycosamine ordered PRN for excess secretions had no direction for staff on what to watch for and when to begin administration of the medication. The need to ensure medication administration records were complete was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 3 (Administrative Assistant) on 10/09/24. The staff acknowledged the findings.

1.) All residents mentioned in SOD have been reviewed by facility RN and corrected to provide resident specific parameters, instructions for PRN medications and monthly vitals where appropriate. 2.) Administrative staff and the facility RN will audit all of the residents MARs to make sure all medications have proper parameters, sequential order, instructions for PRN medications and any special instructions to staff. 3.) On admission, quarterly and at change of condition, facilty RN will audit the residents MAR's ensuring parameters, direction for use and sequential order. 4.) The facility RN will be responsible for corrections and parameters. The Administrator is responsible for monitoring the process and complicance. Both facility RN and Administrator will ensure accurate EMAR.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. 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 ensure MARs were accurate, included medication-specific instructions, and had specific parameters for PRN medications for 4 of 5 sampled residents (#s 1, 2, 3, and 5) whose MARs were reviewed. Findings include, but are not limited to: 1.Resident 3 was admitted to the facility in 05/2019 with diagnoses including Alzheimer’s disease and pica. The resident’s 09/01/24 through 10/07/24 MARs and physician orders were reviewed. The following was identified: *The resident had physician orders for Milk of Magnesia, bisacodyl suppository, and phosphate enema, all PRN for bowel care. There were no parameters for staff to determine the order of administration. *The resident had two as-needed prescriptions for pain, including acetaminophen and morphine sulfate. There were no parameters instructing staff on the order of administration. The need to ensure there were parameters in place for multiple PRN medications for the same purpose was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 10/09/24. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 04/2020 with diagnoses including dementia. The resident's 07/01/24 through 10/07/24 progress notes and physician communications, 08/21/24 signed physician orders, and the 09/01/24 through 10/07/24 MARs/TARs were reviewed and showed the following: * Tylenol 8am dose was not given 09/20/24 through 09/25/24 with reasons noted as prior authorization needed, outside parameters and not arrived. The medication did not have parameters in place, did not require a prior authorization and a house stock was available in the facility. Staff 1 (Administrator) and Staff 2 (RN) were unsure why staff marked the medication as not given with the reasons selected as the medication was available in the house supply in the facility. * The 09/24/24 Amlodipine and 09/24/24 Losartan both for high blood pressure, were held with a note that stated, “outside of parameters.” No vital signs were recorded to show the resident’s blood pressure or pulse were outside the hold parameters ordered by the physician; * A house shake was ordered for the resident four times a day. The shake was frequently circled as not given with reasons noted as refused and out of stock, multiple times within the same day; * Tracheostomy stoma cleaning lacked information for staff on the full process; * Tylenol and Hydrocodone were both ordered PRN for pain, there was no direction for staff on which medication to use first and when; and * Resident specific directions for staff were not documented for the use of Narcan, for opioid overdose reversal. The need to ensure medication administration records were complete was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 3 (Administrative Assistant) on 10/09/24. The staff acknowledged the findings. 3. Resident 2 was admitted to the facility in 04/2024 with diagnoses including dementia. The resident's 07/01/24 through 10/07/24 progress notes and physician communications, 08/15/24 signed physician orders, and the 09/01/24 through 10/07/24 MARs/TARs were reviewed and showed the following: * Tylenol ordered three times a day was circled as not given for the mid-day dose on 09/01/24 and 09/02/24, reason documented as not arrived from pharmacy. The morning and evening doses were given as ordered: * Mirtazapine ordered daily at bedtime to help stimulate appetite, was circled as not given from 09/06/24 to 09/19/24, reason documented as not arrived from pharmacy or prior authorization needed. The doses prior to 09/06/24 and after 09/19/24 were given as ordered with no additional documentation as to why medication would have run out mid-week/mid-month or other follow up; * Tylenol and Hydrocodone were both ordered PRN for pain, there was no direction for staff on which medication to use first and when; * Senna, ordered PRN for constipation had no resident specific directions for staff on when to start the medication; and * Blanks were noted on the MAR related to weekly weight tracking; The need to ensure medication administration records were complete was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 3 (Administrative Assistant) on 10/09/24. The staff acknowledged the findings. 4. Resident 5 was admitted to the facility in 04/2024 with diagnoses including dementia. The resident's 07/10/24 through 10/03/24 progress notes and physician communications, 09/09/24 signed physician orders, and the 09/01/24 through 10/07/24 MARs/TARs were reviewed and showed the following: * Rexulti ordered daily for dementia was circled as not given on 09/12/24, 09/13/24 and 09/16/24, reason documented as not arrived from pharmacy. All other daily doses were signed as administered including 09/14/24 and 09/15/24; * Bisacodyl suppository, Senna and Milk of Magnesia ordered PRN for constipation, there were no resident specific parameters to determine when to use which medication; * Tums ordered PRN for heart burn, indicated chew 1-4 tablets PRN, there was no resident specific parameters for staff to determine how many tablets to give the resident and when; and * Hycosamine ordered PRN for excess secretions had no direction for staff on what to watch for and when to begin administration of the medication; The need to ensure medication administration records were complete was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 3 (Administrative Assistant) on 10/09/24. The staff acknowledged the findings. Based on observation, interview, and record review, it was determined the facility failed to ensure the posted staffing plan was reflective of the staffing needs calculated and the staffing levels exceeded the number of staff indicated by the acuity-based staffing tool. Findings include, but are not limited to: Review of the facility’s ABST entries, staff schedule, calculated staffing hours, and posted staffing plan were completed and showed the following: * Observations of resident care and interviews with staff indicated the current ADL needs for multiple sampled residents were not reflective in the ABST, including an accurate amount of staff time needed to provide care. and * Staff working on the floor matched the posted staffing plan but did not exceed the staff numbers calculated by the ABST. The need to ensure all residents were accurately entered in the ABST and that the facility staffing plan and staff working on the floor, exceeded ABST staffing calculations was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (Administrative Assistant) on 10/08/24 and 10/09/24. The staff acknowl

1.) The ABST will be reviewed by the Administrator and facility RN for each resident in the facility and updated accordingly to reflect care needs. 2.) The Administration team and facility RN will review OAR 411-054-0037 to ensure compliance going forward. The Administrator and facility RN will review current service plans and re-evaluate residents as needed to ensure current needs/staff are reflected accurately. 3.) Within 24 hours before move in, admission, 30 days after admission, quarterly and change of condition. 4.) The Administrator and facility RN will be responsible for compliance.

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 (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 1 of 4 newly hired staff (#16) demonstrated competency in first aid and abdominal thrust within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 10/08/24. The following was identified: There was no documented evidence Staff 16 (CG), hired 09/01/24, had demonstrated competency in first aid and abdominal thrust. The need to ensure all required competencies were demonstrated within 30 days of hire was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 10/08/24. They acknowledged the findings.

1.) Staff 16 no longer works at the facility. 2.) The new hire process has been updated for staff to obtain their first aid and abdominal thrust before they begin their initial training. 3.) The Administrative Assistant will review each new hire file to ensure that training has been completed and will turn the file in to the Administrator for review. 4.) The Administrator will be responsible for compliance.

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 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents were instructed in fire and life safety procedures within 24 hours of admission and at least annually. Findings include, but are not limited to: Fire and life safety records were reviewed and discussed with Staff 1 (Administrator) on 10/08/24. There was no documentation that residents were provided fire training within 24 hours of admission and again at least annually, related to general fire and life safety procedures, evacuation methods, responsibilities, and designated meeting places inside or outside the building in the event of an actual fire. In an interview on 10/08/24, Staff 1 indicated the facility had not been documenting specific training on admission or annually, but all their fire drills were conducted as full evacuations. Staff 1 thought the drills would cover the annually training without any additional documentation. Staff 1 stated she would get information added to the facility admission packet as well as add additional documentation to the evacuations for annual training.

1.) All residents that have resided in the facility for more than a year will receive their annual fire training and this will be documented in their resident chart in EMAR. 2.) The initial fire training will be included during admission. There will be a fire training form added to the facilities admission packet which will require resident and/or legal representative signature. Quarterly evaluations have been updated to include admission date for tracking of annual fire training. 3.) Fire and life safety training will be evaluated upon admission and quarterly. 4.) The Administrator will be responsible for compliance.

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

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. Findings include, but are not limited to: Observations of the facility on 10/07/24 and 10/08/24 showed the following areas in need of cleaning or repair: House A: * Multiple tan sofas and chairs had spills, splatters, rips, or stains; * Brown recliner had multiple large torn areas of vinyl with exposed fabric; and * Multiple pieces of furniture in the living room had spills, splatters, or stains to the seats and arms. House B: * Paisley stuffed chair in the living room had large tears at the edge of the seat with exposed stuffing; and * Multiple pieces of furniture in the living room had spills, splatters, discoloration, or stains to the seats, arms, and/or backs. House C: * Multiple pieces of furniture in the living room had spills, splatters, discoloration, or stains to the seats, arms, and/or backs; and * Tan sofa in a hallway sitting area had stains, spills, and a significantly worn section on the seat. The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Administrator) on 10/08/24. She acknowledged the findings.

1.) Administrator and owner scheduled a visit with a local furniture store representative on 10/17/2024. The representative is preparing an estimate for furniture replacement and length of furniture delivery. 2.) The Administrator and/or Administrative Assistant will check the furniture in all houses for wear and tear. Staff will be instructed to report any noted rips, stains, spills and discoloration to facility Administration. 3.) The furniture in all houses will be evaluated at least once a month. 4.) The Administrator and Administrative Assistant will be responsible for compliance.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by:

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide keys to residents for their entrance doors for 4 of 5 sampled residents (#s 1, 2, 3, and 4). Findings include, but are not limited to: Review of service plans for Residents 1, 2, 3, and 4 revealed they had been evaluated for their ability to use a key and had not been given a key to their entrance door. In an interview with Staff 1 (Administrator) on 10/08/24, she stated keys were not given to residents who were evaluated and found unable to use them appropriately. The need to ensure all residents have a key to their entrance door was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 10/08/24. They acknowledged the findings.

1.) The maintenance department is currently working on getting a key for every resident that resides in the facility. If the resident refuses their key, the key will be placed in their lock box in their room. 2.) A key policy has been added to the facility admission packet. The key policy requires resident and/or representative signature to acknowlege receipt a key to their unit. 3.) This will be evaluated on admission. 4.) The Administrator and Administrative Assistant will be resposible for compliance.

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

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C231, C363, C372, C422, and C513

Refer to C231, C363, C372, C422 & C513

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by:

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure staff training requirements were met related to pre-service orientation and dementia training, demonstration of competency in job duties within 30 days of hire, annual in-service training, and annual infectious disease training. Findings include, but are not limited to: Training records were reviewed on 10/08/24. The following was identified: 1. There was no documented evidence that Staff 11 (CG/MT) had completed the following pre-service orientation and dementia training: * Resident rights and values of CBC care; * Abuse reporting requirements; * Fire safety and emergency procedures; * Written job description; * Infectious Disease Prevention; * Approved HCBS course; * Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to distressful behavior symptoms; * Strategies for addressing social needs and engaging persons with dementia in meaningful activities; * Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach; * Environmental factors that are important to a resident’s well-being (e.g., staff interactions, lighting, room temperature, noise, etc.); * Family support and the role the family may have in the care of the resident; * How to provide personal care to a resident with dementia, including an orientation to the resident’s service plan; and * Use of supportive devices with restraining qualities in memory care communities. 2. There was no documented evidence newly hired Staff 11 (CG/MT) and Staff 16 (CG), both hired 09/01/24, demonstrated competency in one or more of the following areas: * Role of service plans in providing individualized care; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; and * General food safety, serving and sanitation. 3. There was no documented evidence that long-term Staff 10 (CG/MT), hired 12/11/18, had completed the required number of annual in-service training hours between 12/2022 and 12/2023. 4. There was no documented evidence Staff 15 (CG/MT), hired 01/17/18, had completed the required number of annual in-service training hours, including six hours related to dementia care between 01/2023 and 01/2024. 5. There was no documented evidence that long term employees, Staff 10 (CG/MT), Staff 15 (CG/MT), and Staff 17 (CG/MT), hired 12/11/18, 01/17/18, and 05/15/29, respectively, completed annual infectious disease training. 6. There was no documented evidence that long term non-care employee Staff 3 (Admin Asst), hired 08/11/20, had completed annual infectious disease training. The need to ensure staff training requirements were completed within the requisite time periods was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 10/08/24 and 10/09/24. They acknowledged the findings.

1.) An audit of all training files will be completed and staff will be assigned required trainings. 2.) Staff training curriculum will be updated to add all required training hours and topics for yearly and pre service training. 3.) This area will be reviewed on a monthly basis to ensure that staff are in compliance. 4.) The Administrator and Administrative Assistant will be responsible for compliance and that the corrections are completed.

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

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C260, C270, C280, C302, and C310.

Refer to C260, C270, C280, C302 & C310

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by:

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to evaluate residents for activities and to develop individualized activity plans from the evaluations for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) whose service plans were reviewed. Findings include, but are not limited to: A review of service plans for Residents 1, 2, 3, 4, and 5, and interviews with Staff 1 (Administrator) revealed the following: 1. There was no documented evidence of activity evaluations which address the following required elements: * Past and current interests; * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Identification of activities for behavioral interventions. 2. There was no documented evidence individualized activity plans which addressed what, when, how, and how often staff should offer and assist the resident with activities were developed and documented. The need to ensure the facility completed an activity evaluation addressing the required elements and developed an individualized activity plan based on the evaluation for each resident was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 10/09/24. They acknowledged the findings.

1.) The examples pulled have been updated with all of the required topics for activities as well as what, when, how and how often the staff should offer the resident with activities. 2.) Resident evaluations have been updated to include: past and current interests, current abilites and skills, emotional and social needs and patterns, physical abilities and limitations, adaptations necessary for the resident to participate and identification of activities for behavioral interventions. The evaluations have also been updated to include what, when, how and how often the staff should offer the resident with activities. 3.) On Admission and quarterly. 4.) The activities director will complete evaluations quarterly and submit the evaluations to the service planning team. The Administrator and service planning team will be responsible for compliance.

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

OAR 411-057-0170(6) Secure Outdoor Recreation Area (6) SECURE OUTDOOR RECREATION AREA. The memory care community must comply with facility licensing requirements for outdoor recreation areas as well as the following standards. These requirements apply to newly endorsed, constructed, or remodeled communities which have construction documents approved on or after November 1, 2010 with the exception of subsections (d) and (e) of this section. (a) The space must be a minimum of 600 square feet or 15 square feet per resident, whichever is greater and is exclusive of normal walkways and landscaping. The space must have a minimum dimension of 15 feet in any direction; (b) Fences surrounding the perimeter of the outdoor recreation area must be no less than six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition; (c) Walkways must meet the accessibility requirements of the Oregon Structural Specialty Code. Walkway surfaces must be a medium to dark reflectance value to prevent glare from reflected sunlight; (d) Outdoor furniture must be sufficient weight, stability, design, and be maintained to prevent resident injury or aid in elopement; and (e) Doors to the outdoor recreation area may be locked during nighttime hours or during severe weather per facility policy. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure that fencing was no less than six feet in height and constructed to reduce the risk of elopement. Findings include, but are not limited to: A tour of the facility's memory care courtyard for House B, on 10/07/24, showed four sections of black metal fencing that was less than six feet in height. Three sections were located on top of a raised plantar bed area and ranged from 5 ft 5 inches to 5 ft 6 inches in height. The center section had two concrete pillars with a gap between the top of the pillar and the fencing that was approximately 4-5 inches in height. An additional section of black fencing facing the parking lot was measured at 5 ft 9 inches in height. A tour of the perimeter pathways for resident use around House A, on 10/07/24, showed two broken fence slats in the wood fence. Only one resident was noted in the front of House B during survey. The resident came and went to the bench nearest the building with no attempts to go near the fencing. Observations of the current residents who resided in House B, and interviews with staff showed none of the residents appeared to have the strength, balance, or mobility to step up on onto the brick wall at that time. The fencing sections that were less than six feet in height, gaps above the concrete pillars and broken fence slats, was shown to and discussed with Staff 1 (Administrator) and Staff 9 (Maintenance) on 10/07/24 and 10/08/24. They acknowledged the findings.

1.) The maintenance department has contacted two local fencing companies to extend the front and side fences. The center section with the gap between the top of the fence and the concrete pillar has been covered with metal and the broken fence slats have been replaced. 2.) The maintenance department has added observation of the fencing to their walking rounds of the facility grounds. 3.) Monthly walking rounds by the maintenance department and quarterly walking rounds by the Administartor and/or Administrative Assistant. 4.) The maintenance department is responsible for the corrections and the Administrator will be responsible for compliance.

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