OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. Findings include, but are not limited to: During the re-licensure survey, conducted 10/22/24 through 10/28/24, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations. Refer to deficiencies in report.

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure residents’ rights to a safe and homelike environment and to be treated with dignity and privacy. Findings include, but are not limited to: 1. Observations and interviews during the survey on 10/25/24 and 10/28/24, revealed resident room wall heaters were inoperable. Random room temperatures measured during the survey showed temperatures below the required minimum of 70 degrees F during the day. Refer to C 540 2. Observations during the survey revealed that several shared bathroom doors were not lockable for resident privacy. On 10/23/24 at 11:00 am, an interview with Staff 1(ED) confirmed multiple residents who shared a bathroom did not have locks on the bathroom doors. On 10/28/24 at 9:30 am, Staff 4 (Environmental Services Director) confirmed 44 out of 48 resident units had shared bathrooms. All but one of the shared bathrooms were identified to not have a locking system on the door for privacy. The lack of privacy for residents residing in shared apartments was reviewed with Staff 1 (ED), Staff 2 (RN), and Staff 5 (RCC) on 10/28/24 at 3:00 pm. They acknowledged the findings. The need to ensure a resident’s right to privacy in his or her own unit for multiple sampled and unsampled residents was discussed with Staff 1, Staff 2 (RN), and Staff 5 (RCC) on 10/28/24 at 3:00 pm. They acknowledged the findings.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure incidents of abuse or suspected abuse were immediately reported to the local Seniors & People with Disability (SPD) office, failed to promptly investigate incidents of abuse or suspected abuse, and failed to take measures to protect residents and prevent the reoccurrence of abuse for 2 of 2 sampled residents (#s 2 and 3) whose incidents were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 07/2024 with diagnoses including Alzheimer’s disease. Interviews with staff and review of the resident's 09/17/24 service plan and 07/23/24 through 10/24/24 interim service plans, progress notes, and incident investigations were completed. The following was identified: On 10/17/24 an incident report indicated Resident 2 had an injury fall out of bed when s/he “grabbed [his/her] wheelchair but the wheels were not locked … slipped out of bed and sustained a cut to [his/her] leg from the chair and hit [his/her] head.” On 10/18/24 the RN completed a follow-up that stated abuse and neglect were ruled out “as care staff was following” the care plan. However, the follow-up action lacked documented evidence to reasonably conclude the fall was not the result of abuse or neglect. The need to ensure all incidents and injuries of unknown cause contained all required areas of documentation including if abuse could be ruled out, and if not, incidents and injuries of unknown cause were reported to the local SPD office, was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 5 (RCC) on 10/28/24 at 3:00 pm. They acknowledged the findings. The facility was instructed to report the injury of unknown cause to the local SPD office on 10/25/24. Proof of reporting was received from the facility on 10/28/24 at 9:22 pm. 2. Resident 3 was admitted to the MCC in 06/2023 with diagnoses including Alzheimer's disease and was identified in the acuity interview as having resident-to-resident altercations. The resident's 08/05/24 service plan, incident and investigation reports dated 07/15/24 through 10/12/24, and progress notes dated 07/15/24 through 10/23/24 were reviewed. Interviews with staff were conducted. The following was identified: From 07/15/24 through 10/12/24, Resident 3 was involved in seven resident-to-resident altercations. The facility reported the incidents to the local Seniors and People with Disabilities (SPD) office as required; however, the facility investigations of the resident-to-resident altercations lacked evidence a follow-up action plan was documented, including measures taken to prevent future reoccurrence to residents involved and other residents. On 10/28/24, Staff 1 (ED), Staff 2 (RN), and Staff 5 (RCC) acknowledged investigations for resident-to-resident altercations lacked documentation a follow-up action plan was developed. The need to ensure the facility included a follow up action plan for resident-to-resident investigations and to take measures to prevent future occurrences was discussed on 10/28/24 with Staff 1, Staff 2, and Staff 5. They acknowledged the findings.

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs; This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide a daily program of social and recreational activities based upon individual and group interests, and physical, mental, and psychosocial needs. Findings include, but are not limited to: The MCC was divided into two separate units that included two distinct areas within each locked unit. At the time of the survey, the MCC was home to 39 residents. Observations during the survey, from 10/22/24 to 10/24/24, showed a lack of scheduled and unscheduled activities provided for residents living in the MCC. During an interview on 10/22/24 at 11:45 am, Staff 14 (CG) stated that the facility did not have an activity director and that it was the CG’s responsibility to facilitate the activities. The Activity Calendar for October 2024 was provided and indicated scheduled activities for each day of the week. The activities scheduled according to the calendar for 10/22/24, 10/23/24, and 10/24/24 included the following: 10/22/24: * 11:30 am – Chair Yoga * 1:30 pm – Reminiscing with the Office Manager * 2:30 pm - Painting Club: Residents Choice * 3:30 pm – Walking Club Observations at 11:30 am, 1:30 pm, 2:30 pm, and 3:30 pm were made and the activities did not take place. 10/23/24: * 10:00 am – Morning Meeting * 10:30 am – Chair Zumba Group * 1:30 pm – Fitness Club * 2:30 pm - Crafting Club: Wood Slice Pumpkins Observations were made at 10:00 am, 10:30 am, 1:30 pm, and 2:30 pm, and the activities did not take place. 10/24/24: * 10:00 am – Morning Meeting * 11:30 am – Chair Yoga * 1:00 pm – Country Drive with our environmental services director * 2:30 pm – Ice Cream Social * 3:30 pm – Painting Club: Handmade Bookmarks Observations were made at 10:00 am, 11:30 am, 1:00 pm, 2:30 pm, and 3:30 pm, and the activities did not take place. The Activity Calendar for October showed “Dinner” at 4:30 pm as a scheduled activity for each day of the week. In an interview on 10/24/24 at 1:30 pm, Staff 6 (CG) stated there was not enough time or staff to do activities. Throughout the survey, residents were observed wandering the units, entering other resident rooms, sleeping in chairs in the common areas for long periods, sitting in front of the TV, or remaining in their rooms, unengaged in individual or group activities. On 10/24/24 at 2:30 pm, Staff 1 reported he was going to have Staff 20 (Lead MT) and the management team lead activities until a full time Lifestyle Director was hired. The need to ensure the facility provided a daily program of social and recreational activities that were based on individual and group interests and physical, mental, and psychosocial needs was discussed with Staff 1 on 10/25/24. He acknowledged the findings.

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure resident move-in evaluations addressed all required components for 1 of 1 sampled resident (#2), whose move-in evaluation was reviewed, and failed to ensure evaluations were performed at least quarterly, to correspond with the quarterly service plan updates, for 3 of 4 sampled residents (#s 1, 3, and 4) whose evaluations were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 07/2024 with diagnoses including Alzheimer’s disease. The move-in evaluation was reviewed, and there was no documented evidence the following required elements were addressed: * Interests, hobbies, and social and leisure activities; * Cultural preferences and traditions; * History of treatment of mental health issues, including effective non-drug interventions; * Cognition, including memory, confusion and decision-making abilities; * Personality, including how the person copes with change or challenging situations; * Pharmaceutical and non-pharmaceutical interventions for pain; and * Unsuccessful prior placements. The need to ensure move-in evaluations addressed all required elements was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 5 (RCC) on 10/28/24 at 3:00 pm. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 04/2022 with diagnoses including Alzheimer’s disease and arthritis. Review of the resident's quarterly evaluation, dated 08/21/24, observations of the resident, and staff interviews were conducted, which revealed the most recent evaluation did not address all required elements to reflect the current needs and condition of the resident, to include the following: * Falls; * Mobility status; * Two-person assist with transfer and cares; * One-half side rail on bed; * Pain; * Speech – the ability to understand; * Weight loss and gains in the last 180 days; and * Activity abilities. The need to complete quarterly evaluations that address all required elements to reflect the needs and current condition of the resident was discussed with Staff 1 (ED) and Staff 2 (RN) on 10/28/24. They acknowledged the findings. 3. Resident 4 was admitted to the facility in 06/2023 with diagnoses including Alzheimer’s disease. A review of the resident’s quarterly evaluation, dated 08/29/24, was completed, observations were made of the resident, and staff interviews were conducted. The resident’s most recent quarterly evaluation was not reflective of his/her current behaviors related to anxiety. The need to ensure evaluations were reflective of residents’ current status and care needs was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 5 (RCC) on 10/28/24. They acknowledged the findings. 4. Resident 3 was admitted to the MCC in 06/2023 with diagnoses including Alzheimer’s disease. The quarterly evaluation and progress notes dated 07/01/24 through 10/23/24 were reviewed, and interviews were conducted. The quarterly evaluation, dated 08/05/24, failed to accurately describe the resident's current status and condition in the following areas: * Outside mental health provider; * Use of psychotropic medications; * Increased behaviors related to anxiety and agitation; * Resident-to-resident altercations; * Elopement risk; and * Fall risk. In an interview at 3:30 pm on 10/28/24, Staff 2 (RN) acknowledged the lack of documented change of condition updates in the quarterly evaluation. The need to ensure the quarterly evaluation was reflective of the resident's current status and condition was discussed with Staff 1 (ED), Staff 2, and Staff 5 (RCC) on 10/28/24. They acknowledged the findings.

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and preferences, provided clear direction regarding the delivery of services, and/or were implemented for 8 of 8 sampled residents (#s 1, 2, 3, 4, 5, 6, 7, and 8) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 04/2022 and had diagnoses including Alzheimer's Disease and arthritis. Observations of the resident, interviews with staff, review of interim service plans, progress notes from 07/23/24 through 10/22/24, and review of the service plan, dated 08/21/24, showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff, and/or was not implemented in the following areas: * How the resident exhibits agitation; * Coping with challenging situation interventions; * Ability to communicate and understand others; * Two-person assist with transfers and ADL cares; * Ambulation status; * Geri-chair use; * Pressure-relieving cushion in Geri-chair; * Arm sleeves; * One-half side rail on open side of bed; * Pureed food with “thickened liquids”; * Meal assistance; * Health shakes twice daily; * Meal monitoring percentages; * Pain, including the cause and how the resident exhibits pain, and non-drug interventions; * Significant weight changes in the past 180 days; and * Exit-seeking and wandering. The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and/or were implemented was discussed with Staff 1 (ED) and Staff 2 (RN) on 10/28/24. The staff acknowledged the findings. 2. Residents’ 4, 5, 6, 7, and 8 were admitted to the facility with diagnoses including dementia. Observations of the residents, interviews with staff, and review of interim service plans and progress notes from 07/22/24 through 10/22/24 showed the service plans were not reflective of the resident's current behaviors and did not provide clear direction to staff in the following area: * Affectionate physical behaviors towards other residents. Interviews with Staff 6 (CG) and Staff 7 (CG) during survey revealed that Resident 7 often sat with Resident 8, holding hands, hugging, or kissing him/her on the cheek or forehead, and previously had shown the same affection with Resident 4. Resident 5 was reported to be best friends with Resident 6, and some days would lay down in the bed and take a nap with him/her. All staff interviewed reported no further intimate activity involved. The need to ensure resident service plans were reflective of current behaviors and provided direction to staff was discussed with Staff 1 (ED) and Staff 2 (RN) on 10/25/24 and again on 10/28/24. The staff acknowledged the findings and completed an evaluation of the behavior for each resident and added service plan interventions with instruction for staff related to affectionate physical behaviors. 3. Resident 4 was admitted to the facility in 06/2023 with diagnoses including Alzheimer’s disease. A review of the resident’s current service plan, dated 08/29/24, as well as observations of the resident and staff interviews, revealed the service plan was not reflective of the resident’s current status and care needs and did not provide direction regarding the delivery of services in the following area: * Behavior related to anxiety. The need to ensure service plans accurately reflected residents’ current status and care needs, as well as provided clear direction regarding the delivery of services, was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 5 (RCC) on 10/28/24. They acknowledged the findings. 4. Resident 3 was admitted to the MCC in 06/2023 with diagnoses including Alzheimer’s disease. Observations of the resident, interviews with staff, review of the resident's most recent service plan, dated 08/05/24, and interim service plans showed the service plan did not provide clear direction to staff or was not reflective of the resident's needs in the following areas: * Behavioral signs and symptoms of anxiety; * Increased episodes of negative behaviors; * Use of psychotropic medications and effective non-drug interventions; * Resident-to-resident altercations, including interventions to protect residents and prevent future occurrences; * Exit seeking; * Recent falls and interventions to minimize falls; * Use of a four-wheel walker; * Outside providers, including HH, PT, and mental health services being provided; and * Ability to use the call light. The need to ensure service plans were reflective of resident's current care needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 5 (RCC) on 10/28/24. They acknowledged the findings. 5. Resident 2 was admitted to the facility in 07/2024 with diagnoses including Alzheimer’s disease. The resident’s 09/17/24 service plan and 07/23/24 through 10/24/24 interim service plans were reviewed. Observations of the resident and interviews with staff were completed during the survey. The service plan was not reflective of the resident's current status, did not provide clear direction to staff, and/or was not being implemented in the following areas: * Instructions for bleeding precautions while on Eliquis; * Outside providers, including HH PT and OT services being provided; * Pharmaceutical and non-pharmaceutical interventions for pain, including how s/he expressed pain; * Privacy preferences related to keeping the door open; * Ability to use the call light system; * Eating, including diet texture and meal set-up; * Transfer assist, including two-person assist; * Mobility including level of assistance needed, gait belt, and assistive devices used, per HH PT instruction; * Hip precautions following a hip replacement, including use of a pillow between his/her legs when sitting or in bed per HH PT instructions; * Fall precautions including the wheelchair by bedside when in bed; * Physical activity including daily exercises and walking with staff, per HH PT instructions; * Skin conditions including a surgical incision and when to use the barrier cream; and * Evacuation status. The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and were implemented was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 5 (RCC) on 10/28/24 at 3:00 pm. They acknowledged the findings.

OAR 411-054-0036 (5) Service Plan: Service Planning Team (5) SERVICE PLANNING TEAM. The service plan must be developed by a Service Planning Team that consists of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident. Involved family members and case managers must be notified in advance of the service-planning meeting.(a) As applicable, the Service Planning Team must also include:(A) Local APD or AAA case managers and family invited by the resident, as available.(B) A licensed nurse if the resident shall need, or is receiving nursing services or experiences a significant change of condition as required in 411-054-0045(1)(f)(D) (Resident Health Services).(C) The resident's physician or other health practitioner.(b) Each resident must actively participate in the development of the service plan to the extent of the resident's ability and willingness to do so. If resident participation is not possible, documentation must reflect the facility's attempts to determine the resident's preferences. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure a service planning team consisting of the resident, the resident’s legal representative if applicable, any person of the resident’s choice, the facility administrator or designee, and at least one other staff person who was familiar with or who provided services to the resident was involved in updating the service plan for 3 of 4 sampled residents (#s 2, 3, and 4). Findings include, but are not limited to: Current service plans for Residents 2, 3, and 4 were reviewed during the survey. There was no documented evidence a service planning team was involved in updating the residents’ service plans. The need to ensure a service planning team was involved in updating resident service plans was discussed on 10/28/24 with Staff 1 (ED), Staff 2 (RN), and Staff 5 (RCC). They acknowledged the findings.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure short-term changes of condition had actions or interventions communicated to staff on each shift, resident-specific interventions were determined and documented, and the condition was monitored with weekly progress noted until resolution for 4 of 4 sampled residents (#s 1, 2, 3, and 4) who experienced short-term changes in the areas of skin, medication changes, weight loss, diet, and emergency room visits; Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 07/2024 with diagnoses including Alzheimer’s disease. Observations of Resident 2, interviews with staff, and review of the resident's 09/17/24 service plan, 07/23/24 through 10/24/24 interim service plans, 7/23/24 through 10/21/24 progress notes, incident investigations, and outside provider notes were conducted. The following was revealed: * 07/25/24 - redness to the resident’s lower legs; * 09/16/24 - weekly weights; * 09/18/24 - following return from a skilled nursing facility progress notes indicated “there was a bandage on [his/her] L (left) lower shin”; * 09/25/24 - new medication; * 09/26/24 - “rash between [resident’s] thighs; * 09/30/24 - non-injury fall getting up from bed; * 10/01/24 - return from emergency room with a bladder infection; * 10/05/24 - diet change to pureed; * 10/08/24 - weight loss; * 10/10/24 - resident’s legs “super red this morning.”; * 10/10/24 - non-injury fall getting back into bed unassisted; and * 10/17/24 - fall with injury getting out of bed. There was no documented evidence for the above short-term changes of condition that the facility determined what resident-specific actions or interventions were needed for the resident, communicated the determined actions or interventions to staff, and/or documented weekly progress until the condition resolved. The need to ensure actions or interventions for short-term changes of condition were documented and communicated to staff on each shift, and changes of condition were monitored with weekly progress noted through resolution was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 5 (RCC) on 10/28/24 at 3:00 pm. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 06/2023 with diagnoses including Alzheimer’s disease. Observations of Resident 3, interviews with staff, and review of the resident's 08/05/24 service plan, interim service plans, and 07/01/24 through 10/23/24 progress notes were completed. The following was identified: * 07/19/24 - Return from hospital following a right hip fracture and surgery; * 07/29/24 - Staples removed from right hip surgical incision; * 07/30/24 - Fall with complaints of head pain; * 08/01/24 - Staff noted the resident was inconsolable and unable to be redirected; * 08/02/24 - Staff noted “Resident has been pounding on doors, looking for exits and hallucinating about seeing children and animals”; * 08/16/24 - Non-injury fall; * 08/17/24 - Resident-to-resident altercation; * 08/29/24 - Staff noted the resident was physically aggressive towards staff; * 09/04/24 - Resident-to-resident altercation; * 09/13/24 - Resident-to-resident altercation; * 09/18/24 - Resident-to-resident altercation; * 09/20/24 - Resident-to-resident altercation with injury; * 09/23/24 - Staff noted the resident was found outside standing on a chair near the fence, trying to go over it; and * 10/12/24 - Resident-to-resident altercation. There was no documented evidence the facility determined what resident-specific actions or interventions were needed for these changes of condition, that determined actions or interventions were communicated to staff, and/or that progress was documented weekly until the condition resolved. The need to ensure resident-specific actions or interventions were determined and documented for changes of condition, communicated to staff, and progress monitored and documented at least weekly through resolution was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 5 (RCC) on 10/28/24. They acknowledged the findings. 3. Resident 1 was admitted to the facility in 04/2022 with diagnoses including Alzheimer’s disease and arthritis. The resident's 08/21/24 service plan and progress notes, interim service plans, and incident reports dated 07/23/24 through 10/22/24 were reviewed. The following short-term changes of condition lacked actions/interventions determined and monitoring of progress noted weekly through resolution: * 07/29/24 – Pressure wound to the coccyx; * 08/22/24 – Increased dose of melatonin for sleep; * 09/05/24 – Significant weight loss; * 09/21/24 - Vomiting; and * 10/03/24 – Foul odor to coccyx wound. The need to ensure changes of condition had actions/interventions determined and monitored through resolution was discussed with Staff 1 (ED) and Staff 2 (RN) on 10/28/24. They acknowledged the findings. 4. Resident 4 was admitted to the facility in 06/2023 with diagnoses including Alzheimer’s disease. The resident’s 08/29/24 service plan, 07/23/24 through 10/17/24 charting notes, incident reports, interim service plans, and outside provider notes were reviewed. Observations were made of the resident, and staff were interviewed. The resident experienced multiple medication changes between 09/18/24 and 09/26/24. There was no documented evidence these changes were monitored through resolution. The resident experienced an injury fall on 09/26/24. There was no documented evidence the fall was monitored through resolution. In addition, there was no documented evidence interventions were determined, documented, shared with staff, or implemented to prevent additional falls. On 10/28/24 the need to determine, document, communicate to staff on all shifts, implement interventions for short-term changes of condition, and to monitor changes through resolution with at least weekly documentation, was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 5 (RCC). They acknowledged the findings.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 3 of 3 sampled residents (#s 1, 2, and 3) who experienced significant changes of condition. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 04/2022 with diagnoses including Alzheimer’s disease, arthritis, and chronic kidney disease stage III. During the acuity interview on 10/22/24, staff reported Resident 1 had a stage III pressure ulcer to the coccyx. A review of the resident's clinical record dated between 07/23/24 and 10/22/24 identified the following: * 07/29/24 – “Resident on alert for pressure ulcer.” A hospice provider coordination of care note dated 07/31/24 identified the coccyx wound as stage II, which was later determined to be a stage III on 10/17/24. There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment. During an interview with Staff 2 (RN) on 10/23/24 at 2:30 pm, the RN reported she was not aware that a pressure ulcer stage II or higher constituted a significant change of condition and required an RN assessment. The need to ensure an RN assessment was completed for residents who experienced a significant change of condition was reviewed with Staff 1 (ED) and Staff 2 (RN) on 10/28/24. They acknowledged the findings. No further information was provided. 2. Resident 2 was admitted to the facility in 07/2024 with diagnoses including Alzheimer’s disease. The resident's 7/23/24 through 10/21/24 progress notes, 09/17/24 service plan, outside provider notes, and 07/24/24 through 10/08/24 weight records were reviewed. a. On 09/17/24 Resident 2 returned to the facility following a fall on 08/28/24 that resulted in a right hip fracture. The right hip fracture constituted a significant change in condition, requiring a facility RN assessment. * An outside provider note dated 09/20/24 indicated “concern with [his/her] hip incision, swelling … RN present …” Resident was also identified as needing “1-2 person assist for tsf [transfers] … Pt [Patient] is on posterior hip precautions …” * On 09/16/24 an RN assessment was completed and lacked findings and resident status regarding the resident’s change in mobility related to transfers and ambulation ability, hip precautions, and the surgical incision. The RN assessment did identify weekly weights as an intervention, but there was no documented evidence the new intervention by the RN was communicated to staff. b. On 08/20/24, Resident 2 weighed 99.6 pounds. On 10/08/24, the resident weighed 94.4 pounds, which was a weight loss of 5.2 pounds. This constituted a significant change of condition for weight loss of 5.2% in approximately one month. No additional weights were recorded between 8/20/24 and 10/08/24. On 10/25/24 at 9:40 am Staff 2 (RN) indicated the facility’s plan was to get weekly weights on all of the residents and acknowledged Resident 2’s record did not have weekly weights. Staff 2 confirmed she missed identifying Resident 2's significant weight loss and was not able to verbalize a system in place for identifying and managing weight fluctuations. There was no documented evidence there was an RN assessment which included findings, resident status, and interventions made as a result of this assessment. Resident 2's weight during the time of the survey was 100.2 pounds. No additional significant change had occurred. The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made as a result of the assessment for all significant changes of condition was discussed with Staff 1 (ED), Staff 2, and Staff 5 (RCC) on 10/28/24 at 3:00 pm. They acknowledged the findings. 3. Resident 3 was admitted to the MCC in 06/2023 with diagnoses including Alzheimer's disease. Progress notes dated 07/01/24 through 10/23/24 were reviewed, and the following was identified: Resident 3 experienced a fall with a right hip fracture on 07/15/24 and was hospitalized for surgery from 07/15/24 through 07/19/24. The hip fracture and surgery constituted a significant change of condition, for which an RN assessment was required. During an interview at 2:00 pm on 10/28/24, Staff 2 (RN) acknowledged there was no RN assessment completed which documented findings, resident status, and interventions made as a result of the assessment. The need to ensure an RN assessment was completed for residents who experienced significant changes of condition was discussed with Staff 1 (ED), Staff 2, and Staff 5 (RCC) on 10/28/24. They acknowledged the findings.

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure staff were informed of new interventions from outside providers and that service plans were adjusted if necessary for 2 of 4 sampled residents (#s 2 and 4) whose records were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 06/2023 with diagnoses including Alzheimer’s disease. The resident’s 08/29/24 service plan, 07/23/24 through 10/17/24 charting notes, incident reports, interim service plans, and outside provider notes were reviewed. Observations were made of the resident, and staff were interviewed. Resident 4 received services from outside providers, including home health and in-home medical visits. The following was identified: * A progress note dated 08/02/24 documented a home health PT visit, with instructions stating: “Ambulate with [resident] between meal times [sic] at contact assist as long as [resident] can tolerate daily.” There was no documented evidence the intervention was communicated to staff or implemented or that the service plan was updated if necessary. * Staff documented a medical visit in a progress note dated 08/06/24, which included instructions to “continue monitoring [resident] for ABD [abdominal] issues.” There was no documented evidence the instructions were communicated to staff or implemented. * A progress note dated 08/19/24 documented a home health PT visit with the following intervention: continue “ . . . to recommend walker is near by [sic] in case [resident] attempts to get up unassisted.” There was no documented evidence this information was communicated to staff or implemented or that the service plan was updated if necessary. The need to ensure outside provider interventions were communicated to staff and the service plan updated if necessary was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 5 (RCC) on 10/28/24. They acknowledged the findings. 2. Resident 2 was admitted to facility in 07/2024 with diagnoses including Alzheimer’s disease. During the acuity interview on 10/22/24, the resident was identified to receive home health services. Observations of the resident, interviews with staff, review of the service plan dated 09/17/24, interim service plans, progress notes and outside provider notes dated 09/20/24 through 10/22/24 were completed. Resident 2's outside provider notes included the following instruction made by the provider: * 09/20/24 – “Assist 1-2 person for tsf [transfers] … monitor skin with changes in position to prevent … breakdown. Pt [patient] is on posterior hip precautions”; * 10/07/24 - “assist pt in performing [his/her] HEP [home exercise program] daily including walking/standing 2-3X/day to meals”; and * 10/17/24- “Begin to amb [ambulate] to and from room [with] FWW … Pt also should wheel self when able encourage then assist as needed. [S/he] is still on POSTERIOR HIP PRECAUTIONS.” There was no documented evidence staff were informed of new interventions and the service plan adjusted to ensure continuity of care. The need to ensure staff were informed of on-site outside provider information and interventions and the service plan adjusted if necessary was reviewed with Staff 1 (ED), Staff 2 (RN), and Staff 5 (RCC) on 10/28/24 at 3:00 pm. They acknowledged the findings.

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to follow established infection prevention and control protocols to ensure a safe, sanitary, and comfortable environment for 1 of 3 sampled residents (#4) whose ADL care was observed, and meal service for sampled and unsampled residents. Findings include, but are not limited to: 1. Observations of meal service at lunch on 10/23/24 revealed staff was not wearing an apron while serving the meal and assisting residents with eating. 2. Resident 4 was admitted to the facility in 06/2023 with diagnoses including Alzheimer’s disease. A review of his/her current service plan and interviews with staff revealed s/he was dependent on staff for all ADL care, including toileting. On 10/23/24 at 1:00 pm, staff were observed providing incontinence care for Resident 4. Staff did not perform hand hygiene before donning gloves, did not change gloves between “clean” and “dirty” tasks, and did not perform hand hygiene when gloves were removed after the task was completed. In addition, staff did not assist the resident with washing his/her hands after toileting. The need to ensure infection prevention and control protocols were followed was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 5 (RCC) on 10/28/24. They acknowledged the findings.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 2 of 4 sampled residents (#s 3 and 4) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the MCC in 06/2023 with diagnoses including Alzheimer’s disease. The resident's current signed physician orders and 10/01/24 through 10/22/24 MAR were reviewed, and the following was identified: * A treatment order for meal tracking: The physician's order stated, “please input percentage [resident] is eating at each meal.” Scheduled daily at 8:00 am, 12:00 pm, and 6:00 pm. There was no documented evidence on the 10/01/24 through 10/22/24 MAR the facility had carried out the order as prescribed; and * A treatment order for behavior tracking: The physician’s order stated, “please chart any behaviors noted during your shift and any interventions that are effective with redirection.” Scheduled daily at 5:00 am, 1:00 pm, and 11: 00 pm. There was no documented evidence on the 10/01/24 through 10/22/24 MAR the facility had carried out the order as prescribed. During an interview on 10/28/24, Staff 1 (ED), Staff 2 (RN), and Staff 5 (RCC) confirmed the above orders were not followed. The need to ensure all medication and treatment orders were carried out as prescribed was reviewed with Staff 1, Staff 2, and Staff 5 on 10/28/24. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 06/2023 with diagnoses including Alzheimer’s disease. The resident’s 09/01/24 through 10/22/24 MARs and physician orders were reviewed. The following was identified: * A prescription for hydrocodone/APAP 5-325 mg tab (for pain), take 1 tablet by mouth every day as needed for pain; * Resident was administered this medication two times on 09/11/24 and 09/22/24; * A prescription for meloxicam 15 mg (for pain), 1 tablet by mouth every day as needed for pain; and * Resident was administered this medication two times on 09/19/24. The need to carry out medication orders as prescribed was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 5 (RCC) on 10/28/24. They acknowledged the findings.

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure staff administering medications knew the specific reasons for the use of the psychotropic medication for that resident, the common side effects of the medications, and when to contact a health professional regarding side effects, and failed to ensure documented non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medication for 2 of 3 sampled residents (#s 3 and 4) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 06/2023 with diagnoses including Alzheimer’s disease. The resident’s 09/01/24 through 10/22/24 MARs and physician orders were reviewed. The following was identified: * A prescription for olanzapine ODT 5 mg tab (a psychotropic medication), 0.5 tablet by mouth every day as needed for agitation; * The order noted “agitation presents as yelling, pacing or slamming doors.”; * Four non-pharmacological interventions were noted on the MAR; and * PRN olanzapine was administered to the resident six times between 10/01/24 and 10/22/24. Observations of the resident and interviews with staff revealed the resident expressed agitation by continuously repeating s/he didn’t know what to do, asking for help, and saying s/he was sorry. In an interview on 10/28/24, Staff 2 (RN) reported staff should have been documenting non-drug interventions attempted prior to administration of a PRN psychotropic medication in the progress notes. There was no documented evidence staff were attempting and documenting non-pharmacological interventions with ineffective results prior to administering the olanzapine. The need to ensure the specific reasons for use for a PRN psychotropic medication were accurate and that staff attempted and documented non-drug interventions with ineffective results prior to administering PRN psychotropics was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 5 (RCC). They acknowledged the findings. 2. Resident 3 was admitted to the MCC in 06/2023 with diagnoses including Alzheimer's disease. A review of the resident's 10/01/24 through 10/22/24 MAR, current physician orders, and 07/01/24 through 10/23/24 progress notes identified the following: * Resident 3 had a signed physician order for lorazepam 0.5 mg, one tablet by mouth every day as needed for increased anxiety and agitation; * The MAR did not provide instructions to non-licensed staff regarding how the resident demonstrated signs and symptoms of anxiety or agitation behaviors for which staff could consider administering the medication; * There were no resident-specific non-pharmacological interventions; * There were no non-pharmacological interventions documented in the resident's chart as having been attempted and ineffective prior to the PRN lorazepam being administered on 10/01/24, 10/03/24, 10/14/24, 10/16/24, 10/19/24, and 10/22/24; and * The MAR lacked common side effects of the medication and lacked instructions for when to contact a health professional regarding side effects. The need to have written, resident-specific parameters for PRN psychotropic medications, and to document non-pharmacological interventions attempted and ineffective prior to administration of a PRN psychotropic, was reviewed with Staff 1 (ED), Staff 2 (RN), and Staff 5 (RCC) on 10/28/24. They acknowledged the findings.

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed by an RN, PT, or OT, other less restrictive alternatives evaluated prior to use of the device were documented, caregivers were instructed on the correct use of and precautions for the device, and use of the device was included in the resident's service plan for 1 of 1 sampled resident (#1) who had a half side rail on their bed and used a Geri-chair. Findings include, but are not limited to: Resident 1 was admitted to the facility in 04/2022 with diagnoses which included Alzheimer’s disease and arthritis and was receiving hospice services. During the acuity interview on 10/22/24, staff reported the resident used a Geri-chair when out of bed. On 10/22/24 at 1:12 pm, the resident's bed was observed to have a half-length side rail in the up position on the open side of the bed, and a Geri-chair by the resident’s closet. There was no documented evidence the devices with restraining qualities had been assessed by an RN, PT, or OT, no documentation of other less restrictive alternatives evaluated prior to use of the devices, no documentation of instruction to caregivers on correct use of and precautions for the device, and no documentation of the use of the side rails in the resident's service plan. The above information was discussed with Staff 1 (ED) and Staff 2 (RN) on 10/28/24. Staff 2 acknowledged the resident's record lacked an assessment by an RN, PT, or OT, documentation of other less restrictive alternatives evaluated prior to use of the device, instruction to caregivers on correct use of and precautions for the device, and documentation in the service plan.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to have a sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident and to meet the fire safety evacuation standards during the night shift. Findings include, but are not limited to: a. On 10/22/24 during the entrance conference, survey requested a facility staffing policy and a copy of the facility’s acuity-based staffing tool (ABST). Staff 1 (ED) stated the facility used a proprietary ABST to determine staffing levels. The ABST was reviewed during the survey. The ABST being used by the facility was not accurately determining the correct staffing minutes, had not been approved by the Department, and did not include all residents currently residing in the facility. Refer to C361 and C362. b. During the acuity interview on 10/22/24 and in observations/ interviews with staff, the following was identified: * The facility was home to 39 residents, in two segregated units that included two distinct areas within each locked unit; * Five residents required a two-person assist transfer, with two requiring two-person assist with all cares; * Five residents required cueing, set-up, or feeding assistance; * Five residents were identified as a fall risk; and * Seven residents were identified as having resident-to-resident behaviors, exit-seeking behaviors, and/or needing one-on-one assistance from staff when having behaviors. c. The staffing plan provided by the facility “as of 10/14/24” was as follows: * Day shift: 6:00 am to 2:00 pm - two med techs, four caregivers; * Swing shift: 2:00 pm to 10:00 pm - one med tech, four caregivers; and * Night shift: 10:00 pm to 6:00 am - one med tech, two caregivers. d. Observations on the two locked units (100/200 and 300/400) throughout survey showed the following: * Residents seated at tables looking around or sleeping in their chairs, others wandering around the units, and some residents seated in front of the television at times; * Lack of scheduled or unscheduled activities between 10/22/24 and 10/25/24; * Care staff were not present on a unit for up to 30 minutes at a time when on breaks; * Meals were not served in a timely manner, sometimes sitting on the cart for up to 20 minutes; and * Residents were left unattended in dining rooms during meals. e. During interviews conducted 10/22/24 through 10/28/24, family and staff stated the following: * A CG reported, “By the time we have completed everything, everyone is asleep, and we do not have time for activities.” * A CG reported that one caregiver was assigned to each of the four units and one MT assigned two units on day and evening shifts. The CG stated that there was not enough staff to be able to take care of the residents, serve and assist with meals, and set up and lead activities. * On 10/22/24, at approximately 2:30 pm, in an interview with Staff 1 (ED), it was discussed that the night shift staffing of two CGs and one MT was not adequate to ensure resident care and supervision was provided according to resident needs and preferences, as well as it being an inadequate number of staff for safe resident evacuations, breaks, and care of residents who needed two-person assistance. Staff 1 agreed to increase the night shift staff to three CG’s and one MT effective immediately. * On 10/23/24 at 2:30 pm, concerns with the units not having adequate staff to meet the residents’ 24-hour care needs on day and evening shift was discussed with Staff 1, including units left unattended when CGs went to lunch or on breaks, the lack of any scheduled or unscheduled activities, late meal service, and the multiple residents that needed two-person assistance for care and/or transfers. Staff 1 stated that the number of staff scheduled was based on the ABST and acknowledged that he had not considered the facility design. The facility failed to ensure a sufficient number of caregivers were available to meet the 24-hour scheduled and unscheduled needs of each resident and fire evacuation standards related to the multiple residents who required the assistance of two care staff for transfers and had high levels of care needs. Staff 1 provided an amended staffing plan to the survey team on 10/25/24 at 1:45 pm. The need to have a sufficient number of staff on all shifts to meet all scheduled and unscheduled needs of residents was discussed with Staff 1, Staff 2 (RN), and Staff 5 (RCC) on 10/28/24 at 3:00 pm. They acknowledged the findings.

OAR 411-054-0037 (1a)(2-3) Acuity Based Staffing Tool - Elements (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING. Facilities must select and implement an acuity-based staffing tool (ABST) that is technology-based for determining appropriate staffing levels. Individual resident needs and care elements must be the primary consideration when developing and maintaining an ABST. Regardless of the ABST adopted, all requirements set forth in this rule and OAR 411-054-0034 (Resident Move in Evaluation) must be met. Facilities shall: (a) Select and implement the Department’s developed ABST or submit a proprietary ABST to the Department for approval as outlined in paragraph (2) of this rule. (2) PROPRIETARY ABST. A facility that chooses to use a proprietary ABST must implement a Department-approved ABST that meets this rule. (a) REQUIRED ELEMENTS. The proprietary ABST the facility adopts must meet the following requirements: (A) Address and document all individual ABST care elements outlined in paragraph (3) of this rule. (B) When calculating total time, the ABST must include the care elements for each resident and staff time needed to complete each individual care element. (C) Ensure the ABST can produce a report that identifies all residents currently residing in the facility, the care elements for each of the residents, and the staff time required to complete each care element for each resident. (D) Ensure the ABST can present the total time, in minutes, required to meet the scheduled needs for all residents, 24 hours a day, seven days a week, preferably per shift, per day. (E) Identify the date the resident’s ABST evaluation was last completed. (F) If applicable, determine ABST time for both residents on a Specific Needs Contract and residents not on a Specific Needs Contract to build posted staffing plans as outlined in this rule. (b) PROPRIETARY ABST REVIEW REQUEST. If a facility proposes to use a proprietary ABST, the facility must submit the ABST Proprietary Department Review Request (PDRR) Form, including but not limited to the following: (A) All facilities which currently have implemented a proprietary ABST must submit a PDRR Form no later than August 31, 2024. Facilities which do not submit a request on or before August 31, 2024, will be subject to corrective action as outlined in paragraph (9) of this rule. (B) Completed ABST PDRR Form. (C) Sample ABST report displaying all the ABST care elements listed in paragraph (3) of this rule, and the estimated staff time needed to complete each care element, shown per day, in minutes. Although not required, it is preferred that staff time be shown per shift, per day, in minutes. (D) The facility’s ABST policy required under OAR 411-054-0025(7)(i). (c) ABST SUMMARY STATEMENT. If the proprietary review request is approved, a facility must develop and maintain an ABST Summary Statement. The summary statement must be available upon request by the Department. An ABST summary statement must contain a general guide of how the ABST functions, as outlined on the PDRR form. (d) DEPARTMENT REVIEW OF PROPOSED PROPRIETARY ABST REQUEST. The Department will review and either approve or deny the facility’s proprietary ABST. The Department may request additional documentation, potentially including a virtual demonstration, to make the determination. If the ABST is deemed to not meet this rule, the Department may deny or rescind approval at any time. (e) APPEALS PROCESS. The Department will determine whether to approve or deny the request. If the proprietary ABST is denied or rescinded, the facility is entitled to a contested case hearing pursuant to ORS chapter 183. Prior to a contested case hearing, the facility may request an informal conference. (f) ANNUAL STATEMENT. Once approved, the facility must provide the Department an annual statement attesting no substantive changes have occurred to the design of the facility’s proprietary ABST that impacts its functionality. The facility must submit statements to the Department every year, between January 1 and March 31. (g) If the facility makes substantive changes to the design of its proprietary ABST that impacts the ABST’s functionality and if such changes would make the information submitted in support of its approval inaccurate or invalid, the facility must re-submit the ABST PDRR Form as described in this rule to the Department for review prior to implementing the new or revised ABST. (3) ABST CARE ELEMENTS. The required ABST care elements include activities of daily living and other tasks related to resident care and services, as outlined in OAR 411-054-0030, 411-054-0034, and 411-057- 0160. If any individual care element requires more than one staff, additional time must be accounted for as described in 411-054-0070(1). The ABST must individually address and document the care time required to complete each of the following individual ABST care elements: (a) Personal hygiene. (b) Grooming. (c) Dressing and undressing. (d) Toileting, bowel, and bladder management. (e) Bathing. (f) Transfers. (g) Repositioning. (h) Ambulation. (i) Supervising, cueing, or supporting while eating. (j) Medication administration. (k) Providing non-drug interventions for pain management. (l) Providing treatments. (m) Cueing or redirecting due to cognitive impairment or dementia. (n) Ensuring non-drug interventions for behaviors. (o) Assisting with leisure activities, assist with social and recreational activities. (p) Monitoring physical conditions or symptoms. (q) Monitoring behavioral conditions or symptoms. (r) Assisting with communication, assistive devices for hearing, vision, and speech. (s) Responding to call lights. (t) Safety checks, fall prevention (u) Completing resident specific housekeeping or laundry services performed by care staff. (v) Providing additional care services. If additional services are not provided, this element can be omitted. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to implement a proprietary ABST that was Department-approved. Findings include, but are not limited to: On 10/25/24 at 8:45 am the facility’s proprietary ABST was reviewed with Staff 1 (ED). There was no documented evidence the Department approved the facility’s proprietary tool. No additional information was provided. The need to ensure the facility implemented a Department-approved ABST was discussed with Staff 1 on 10/25/24 at 8:45 am. He acknowledged the findings.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to complete an acuity-based staffing tool (ABST) assessment for each resident that addressed all the required ADLs, failed to determine the amount of staff time required to provide care, and failed to ensure the ABST effectively determined appropriate staffing levels for the facility. Findings include, but are not limited to: On 10/23/24 at 11:52 am, the facility provided a copy of the proprietary ABST for the current residents, however was missing one unsampled resident’s ABST data. On 10/25/24 at 8:45 am, Staff 1 (ED) acknowledged the facility’s ABST did not have all of the current residents entered, and, therefore, the tool did not accurately determine the correct amount of staff time required to provide care to the residents that could be used to develop the facility staffing plan. The need to ensure the facility's ABST included all residents in order to determine appropriate staffing levels for the facility and to meet the 24-hour scheduled and unscheduled needs of the residents was discussed with Staff 1 on 10/25/24 at 8:45 am. He acknowledged the findings.

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 4 of 4 newly hired staff (#s 7, 9, 11, and 13) demonstrated competency in all required areas within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed, and the following was identified: There was no documented evidence that Staff 7 (CG), Staff 9 (MT/CG), Staff 11 (MT), and Staff 13 (CG), hired 09/01/24, 09/08/24, 09/09/24, and 09/01/24, respectively, had demonstrated competency in one or more of the following areas: * First aid; and * Abdominal thrust. The need to ensure newly hired staff demonstrated competency in all required areas within 30 days of hire was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (Business Office Manager), and Staff 5 (RCC) on 10/28/24. They acknowledged the findings.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with the Oregon Fire Code and that fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to: Fire and life safety records, reviewed between 05/2024 and 09/2024, showed fire drill documentation was lacking in the following areas: * The escape route used; * Evacuation time-period needed; * Evidence of alternate routes used; and * Staff interviewed did not know the designated point of safety. Additionally, the records reviewed did not show life safety training was provided on alternate months from fire drills. The need to ensure all required components were addressed and documented for each fire drill, and that drills were conducted on alternate months from fire and life safety training, was discussed with Staff 1 (ED) and Staff 4 (Environmental Services Director) on 10/24/24. The staff acknowledged the findings.

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all chemicals and other toxic materials were in a locked storage unit and exterior pathways were maintained in good repair. Findings include, but are not limited to: During a tour of the MCC on 10/22/24 at 11:20 am, the following was identified: * Cleaning chemicals and disinfectants were found accessible to the residents in unlocked cupboards of the dining room kitchenettes in the 100, 200, 300, and 400 areas; and * The exterior pathways of the courtyards and fenced patio areas contained multiple drop-offs, up to approximately two and one-half inches in depth, along the pathway edges. The drop-offs created a potential trip/fall hazard for residents who used the pathways. The need to ensure all chemicals and other toxic materials were in a locked storage unit and exterior pathways were maintained in good repair was discussed with Staff 1 (ED) and Staff 4 (Environmental Services Director) on 10/25/24 and 10/28/24. They acknowledged the findings.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the facility was clean and in good repair. Findings include, but are not limited to: Observations of the MCC on 10/22/24 and 10/23/24 showed the following areas in need of cleaning and/or repair: * Counters, cupboards, and drawers in the dining room kitchenettes were chipped, scratched, and peeling, with exposed particle board and wood surfaces; * Several dining room chairs and tables had stains, spills, and chips/scrapes to wooden legs and arms; * Multiple common area chairs and sofas had torn upholstery, spots, and stains; * The floor in the laundry room had large pieces of flooring that were missing and/or peeling under the commercial washer and dryer; and * The window tracks inside resident rooms had an accumulation of dirt, dust, and dead insects. The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (ED) and Staff 4 (Environmental Services Director) on 10/25/24 and 10/28/24. They acknowledged the findings.

OAR 411-054-0200 (8) Heating and Ventilation (8) HEATING AND VENTILATION SYSTEMS. A RCF must have heating and ventilation systems that comply with the building codes in effect at the time of facility construction. (a) TEMPERATURE. For all areas occupied by residents, design temperature for construction must be 75 degrees Fahrenheit. (A) A RCF must provide heating systems capable of maintaining 70 degrees Fahrenheit in resident areas. Required minimum temperatures are no less than 70 degrees Fahrenheit during the day and 60 degrees Fahrenheit during sleeping hours. (B) During times of extreme summer heat, fans must be made available when air conditioning is not provided. (b) EXHAUST SYSTEMS. All toilet and shower rooms must be equipped with a mechanical exhaust fan or central exhaust system that discharges to the outside. (c) FIREPLACES, FURNACES, WOODSTOVES, AND BOILERS. Where used, installation must meet standards of the building codes in effect at the time of construction. The glass and area surrounding the fireplace must not exceed 120 degrees Fahrenheit. (d) WALL HEATERS. Covers, grates, or screens of wall heaters and associated heating elements may not exceed 120 degrees Fahrenheit when they are installed in locations that are subject to incidental contact by people or with combustible material. Effective 01/15/2015, wall heaters are not acceptable in new construction or remodeling. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to provide heating systems capable of maintaining 70 degrees Fahrenheit (F) in resident areas. Findings include, but are not limited to: During an interview on 10/25/24 at 9:45 am with Staff 6 (CG), it was revealed that resident room wall heaters were no longer operating, and all heating units in resident rooms had been turned off. In an interview on 10/25/24 at 10:00 am, Staff 4 (Environmental Services Director) confirmed that all resident room wall heaters had been turned off due to the faceplates exceeding 170 degrees F and the wall heaters were accessible to incidental contact. During the survey, on 10/25/24 and 10/28/24, observations revealed temperatures inside resident rooms were consistently below 70 degrees F during daytime hours. Temperatures obtained with Staff 4 included the following: * 10/25/24 at 11:09 am, room 346 was 67 degrees F; * 10/25/24 at 11:10 am, room 347 was 68 degrees F; * 10/25/24 at 11:15 am, room 144 was 67 degrees F; * 10/28/24 at 9:30 am, room 250 was 69 degrees F; * 10/28/24 at 9:32 am, room 344 was 68 degrees F; and * 10/28/24 at 9:33 am, room 346 was 65 degrees F. On 10/28/24 at 9:30 am, an unsampled resident was observed in their room with a coat on. When asked about their room temperature and the use of a coat, the resident replied,” ... I’m freezing.” During an interview on 10/28/24 at 10:15 am, Staff 9 (MT) reported the residents were consistently cold when waking up and going to bed at night. On 10/25/24 at 12:10 pm, Staff 1 (ED) reported that the facility had disconnected all resident room wall heaters in March 2024. Staff 1 stated that the facility had been actively working on this issue. On 10/25/24 at 1:14 pm, the survey team, CBC survey manager, and the facility’s Operation Policy Analyst and Correction Action Coordinator, initiated a conference call with Staff 1 and Staff 19 (Regional Director of Operations) to address how the facility would provide a heating system capable of maintaining 70 degrees F in resident areas. Staff 1 and Staff 19 agreed to provide a plan and follow up with the policy analyst daily until a sufficient plan was established. The need to ensure resident areas could be maintained at a minimum of 70 degrees F in resident areas was discussed with Staff 1, Staff 2 (RN), Staff 3 (Business Office Manager), Staff 5 (RCC), and Staff 20 (Lead MT) on 10/28/24. The staff acknowledged the findings.

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to: Observations of the MCC environment from 10/22/24 through 10/25/24, revealed there were no functioning exit door alarms that alerted staff when residents exited into the secured courtyards and fenced patio areas. During a walkthrough of the environment on 10/25/24 at 2:30 pm, Staff 1 (ED) and Staff 4 (Environmental Services Director) verified that the alarms were “turned off.” On 10/25/24 at 2:35 pm, the need to ensure exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the building was discussed Staff 1 and Staff 4. They acknowledged the findings.

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure residents’ rights of privacy in his or her own unit for multiple sampled and unsampled residents. Findings include, but are not limited to: Refer to C200.

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the individual and only appropriate staff had a key to access their unit for multiple sampled and unsampled residents. Findings include, but are not limited to: During an interview on 10/23/24 at 11:00 am, Staff 1 (ED) confirmed the majority of the residents did not have keys to their units. The need to ensure the individual and only appropriate staff had a key to access their unit was discussed with Staff 1, Staff 2 (RN), and Staff 5 (RCC), on 10/28/24 at 3:00 pm. They acknowledged the findings.

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 C150, C200, C231, C242, C295, C360, C361, C362, C372, C420, C510, C513, C540, and C555.

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 4 of 4 long term direct care staff (#s 6, 8, 10, and 15) completed the required number of annual in-service training hours, 2 of 4 long term direct care staff completed annual infectious disease training, and 1 of 2 long term non-care staff completed annual infectious disease training. Findings include, but are not limited to: A review of staff training records identified the following: * There was no documented evidence that Staff 6 (CG), Staff 8 (CG), Staff 10 (CG), and Staff 15 (CG), hired 05/19/20, 05/17/20, 08/08/22, and 06/02/20, respectively, had completed at least 10 hours of annual in-service training related to the provision of care in CBC, from their anniversary date in 2023 to their anniversary date in 2024. * There was no documented evidence that Staff 15 (CG), hired 06/02/20, had completed a minimum of 6 hours of annual in-service training related to dementia care. * There was no documented evidence that Staff 6 and Staff 10 had completed the required annual infectious disease training. * There was no documented evidence that Staff 4 (Environmental Services Director), hired 07/02/18, had completed the required annual infectious disease training. The need to ensure staff training requirements were completed in the specified time frames was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (Business Office Manager), and Staff 5 (RCC) on 10/28/24. They acknowledged the findings.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to: C252, C260, C262, C270, C280, C290, C303, C330, and C340.

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in residents' service plans for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose nutrition and hydration plans were reviewed. Findings include, but are not limited to: Service plans for Residents 1, 2, 3, and 4 were reviewed during survey. Each of the service plans included some food preferences but lacked accurate and/or individualized nutrition and hydration information and staff instructions related to meeting resident-specific nutrition and hydration needs. The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (ED) and Staff 2 (RN) on 10/28/24. They acknowledged the findings.

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure all required elements were addressed in resident activity evaluations and individualized activity plans were developed for each resident based on their activity evaluation for 4 of 4 sampled residents (#s 1, 2, 3, and 4). Findings include, but are not limited to: Records for Residents 1, 2, 3, and 4 were reviewed, observations were made, and staff interviews were conducted. The following was identified: 1. There was no documented evidence of activity evaluations for each resident which addressed 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 for each resident. 3. None of the scheduled activities were observed to occur in the community during the survey (10/22/24 through 10/24/24). Refer to C242. The need to ensure the facility completed an activity evaluation addressing the required elements, developed an individualized activity plan based on the evaluation for each resident, and implemented meaningful activities was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 5 (RCC) on 10/28/24. They acknowledged the findings.

OAR 411-057-0170(6) Secure Outdoor Recreation Area (6) SECURE OUTDOOR RECREATION AREA. The memory care community must comply with facility licensing requirements for outdoor recreation areas as well as the following standards. These requirements apply to newly endorsed, constructed, or remodeled communities which have construction documents approved on or after November 1, 2010 with the exception of subsections (d) and (e) of this section. (a) The space must be a minimum of 600 square feet or 15 square feet per resident, whichever is greater and is exclusive of normal walkways and landscaping. The space must have a minimum dimension of 15 feet in any direction; (b) Fences surrounding the perimeter of the outdoor recreation area must be no less than six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition; (c) Walkways must meet the accessibility requirements of the Oregon Structural Specialty Code. Walkway surfaces must be a medium to dark reflectance value to prevent glare from reflected sunlight; (d) Outdoor furniture must be sufficient weight, stability, design, and be maintained to prevent resident injury or aid in elopement; and (e) Doors to the outdoor recreation area may be locked during nighttime hours or during severe weather per facility policy. This Rule is not met as evidenced by: Based on observation, interview, and record review it was determined the facility failed to ensure outdoor furniture was of sufficient weight, stability, and design to prevent resident injury or aid in elopement. Findings include, but are not limited to: Resident 3 moved into the MCC in 06/2023 with diagnoses including Alzheimer’s disease. A review of Resident 3’s progress notes from 07/01/24 to 10/23/24 revealed that on 09/23/24, the resident was found on a chair near the fence trying to go over it. The facility grounds of the memory care community were toured on 10/22/24 through 10/25/24. Outdoor furniture was observed in the secured courtyards and fenced patio areas, to which residents had free access. The furniture was movable, and not of sufficient weight to prevent injury or elopement. On 10/25/24, the outdoor courtyards and fenced patio areas were toured with Staff 1 (ED) and Staff 4 (Environmental Services Director) and the need to have outdoor furniture of sufficient weight was discussed. They acknowledged the findings. On 10/25/24, the survey team instructed the facility to remove the outdoor furniture until they obtained furniture of sufficient weight or could secure it.