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 11/18/24 through 11/21/24, 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 the deficiencies identified in the report.

1. Facility Administrator will provide daily oversight to ensure adequate resident care & services are rendered. 2. Facility Administrator will participate in daily clinical meetings and monthly Quality Improvement meetings. 3. Daily/Monthly. 4. Facility Administrator.

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:

OAR 411-054-0025 (8) Facility Administration: Records (8) RECORDS. The facility must ensure the preparation, completeness, accuracy, and preservation of resident records. (a) The facility must develop and implement a written policy that prohibits the falsification of records. (b) Unless required or allowed by state or federal law, a facility shall not disclose any personally identifiable information regarding: (A) A resident’s sexual orientation; (B) Whether a resident is LGBTQIA2S+; (C) A resident’s gender transition status; or (D) A resident’s human immunodeficiency virus status. (c) The facility shall take appropriate steps to minimize the likelihood of inadvertent or accidental disclosure of information described in subsection (b) of this section to other residents, visitors or facility staff, except to the minimum extent necessary for facility staff to perform their duties. Facilities must notify residents or resident representatives if a resident is affected by a disclosure of information. (d) Resident records must be kept for a minimum of three years after the resident is no longer in the facility. (e) Upon closure of a facility, the licensee must provide the Department with written notification of the location of all records. Name: This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to maintain complete and accurate records for 2 of 4 sampled residents (#s 4 and 5). Findings include, but are not limited to: 1. On 11/18/24, the survey team requested a copy of six months of monthly weight records for Residents 4 and 5. The facility was unable to produce six months of weights for the sampled residents. During an interview, on 11/18/24 at 3:40pm, Staff 1 (Administrator) reported monthly vitals/weights were being shredded at the end of every month and they were unable to produce six months of weights. Staff 1 reported a new policy would be implemented to stop shredding resident monthly weights. On 11/18/24, the need to ensure resident records were complete was discussed with Staff 1. She acknowledged the findings.

1. The facility policy has been reviewed and staff trained to keep all resident records including weight and vital history. 2. Weight monitoring system has been implemented. Residents weights and vitals will be taken monthly no later than the 10th of every month.These will be reviewed at the monthly weight meeting that is scheduled for the 3rd Thursday of every month. A weight tacking tool is used to track any fluctuation that may require additional monitoring/interventions. 3. Monthly 4. Facility Administrator/LN.

OAR 411-054-0025 (8) Facility Administration: Records (8) RECORDS. The facility must ensure the preparation, completeness, accuracy, and preservation of resident records. (a) The facility must develop and implement a written policy that prohibits the falsification of records. (b) Unless required or allowed by state or federal law, a facility shall not disclose any personally identifiable information regarding: (A) A resident’s sexual orientation; (B) Whether a resident is LGBTQIA2S+; (C) A resident’s gender transition status; or (D) A resident’s human immunodeficiency virus status. (c) The facility shall take appropriate steps to minimize the likelihood of inadvertent or accidental disclosure of information described in subsection (b) of this section to other residents, visitors or facility staff, except to the minimum extent necessary for facility staff to perform their duties. Facilities must notify residents or resident representatives if a resident is affected by a disclosure of information. (d) Resident records must be kept for a minimum of three years after the resident is no longer in the facility. (e) Upon closure of a facility, the licensee must provide the Department with written notification of the location of all records. Name: This Rule is not met as evidenced by:

OAR 411-054-0025 (9) Facility Administration: Quality Improvement (9) QUALITY IMPROVEMENT PROGRAM. The facility must develop and conduct an ongoing quality improvement program that evaluates services, resident outcomes, and resident satisfaction. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, staff performance, resident outcomes, and resident satisfaction. Findings included, but are not limited to: During the survey, conducted 11/18/24 through 11/21/24, quality improvement oversight to ensure adequate resident care, services, satisfaction, and staff performance was found to be ineffective. Refer to the deficiencies in the report.

1. Quality Improvement Program has been developed and will meet the 4th Thursday of every month. 2. Administrator or designee will implement and facilitate the meeting with all department heads. 3. Monthly 4. Facility Administrator

OAR 411-054-0025 (9) Facility Administration: Quality Improvement (9) QUALITY IMPROVEMENT PROGRAM. The facility must develop and conduct an ongoing quality improvement program that evaluates services, resident outcomes, and resident satisfaction. This Rule is not met as evidenced by:

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 conduct investigations of injuries of unknown cause to rule out abuse or report the injuries as suspected abuse to the local Seniors and People with Disabilities (SPD) office, for 1 of 1 sampled resident (#4). Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 03/2024 with diagnoses including osteoarthritis. Resident 4's clinical records, including evaluations, service plans, interim service plans, incident reports/investigations, and progress notes, were reviewed during survey, and interviews with staff and Resident 4 indicated the following: * A progress note, dated 09/18/24, indicated Resident 4 had a “small sore in the middle of upper chest” and “No further redness noted. Spot appears healed. Will discontinue alert charting.” No other clinical records were found identifying the specific sore or how the sore occurred. During an interview on 11/21/24, Staff 1 (Administrator) reported there was no documented evidence of an investigation into how the injury occurred or ruling out possible abuse. On 11/21/24, the need to ensure all injuries of unknown cause were immediately investigated to rule out abuse and were promptly reported to the local SPD office was discussed with Staff 1, Staff 2 (Administrator in Training), and Staff 5 (RN). They acknowledged the findings. At survey's request, the facility reported the incident to the local SPD office. Confirmation of the report was provided to survey prior to exit.

1. The incident dated 9/18/2024. Self report was sent to SPD and they sent a receipt notification. The investigation into the "spot" was difficult to complete as to the age of the incident and lack of documentation. However when I talked with the family and the resident there was no concern noted for the any of the cares provided for Linda, or concern regarding abuse or neglect from our care staff. 2. A. Incident reports have been implemented and facility staff trained on proper completion of report, witness statements and follow up monitoring and reporting to supervisor and state & local offices. Ongoing training will be given to staff. B. Incident reports will be reviewed and completed during morning clinical meetings. They will verify that the alert charting is happening as required, the investigations are completed timely, and review for any issues that should be reported to SPD. C. Any identified incidents or incident reports that can not rule out abuse or neglect or look suspicious will immedately be self reported to the local SPD Office. Then within OAR guildines investigations will be completed and the follow-up information including the investigation, followup action taken, and outcome will be sent to the SPD Office. C. The local office APS reporting line has been given to all staff and is posted in several key areas throughout the building. 3. A. All incident reports will be reviewed at the daily clinical meeting to ensure proper investigation has been completed, interventions implemented as needed, proper follow and monitoring is in place and local/state offices have been notified if needed. B.Incident reports and proper investigation will also be monitored through the monthly QI program for the next three months and then will be reviewed quarterly for ongoing review. 4. Admin/RCC/RN

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

OAR 411-054-0034 (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 all required elements were addressed in the move-in evaluation for 1 of 1 newly admitted resident (# 2), failed to ensure 2 of 2 sampled residents’ (#s 1 and 5) evaluations were completed quarterly, and failed to ensure timely completion of quarterly smoking evaluations for 2 of 2 sampled residents who were smokers (#s 1 and 3). Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 11/2024 with diagnoses including congestive heart failure. Resident 2's move-in evaluation, dated 11/05/24, was reviewed during survey. The following required elements were not addressed: * Pronouns; * Gender identity; and * Personality, including how the person copes with change of challenging situations. The need to address all required elements in the move-in evaluation was discussed with Staff 1 (Administrator), Staff 2 (Administrator in Training), and Staff 5 (RN) on 11/21/24. No additional information was provided. 2. Resident 5 was admitted to the facility in 04/2016 with diagnoses including diabetes, hypertension, asthma, and neuropathy. Resident 5’s record was reviewed, including resident evaluations. The following was identified: * An evaluation was started on 05/20/24, although not signed as complete until 11/18/24. Staff 7 (RCC) reported that the evaluation was in the electronic medical record system, although had never been signed and dated as complete until evaluations were requested by surveyor on 11/18/24. She was unsure if the information was reflective of the resident’s current needs and status. * An evaluation started on 02/20/24 was signed as complete on 07/10/24. *There was no documented evidence an evaluation was completed with updated resident information after 07/10/24. The need to ensure resident evaluations were completed at least quarterly was discussed with Staff 1 (Administrator), Staff 2 (Administrator in Training), and Staff 5 (RN) on 11/21/24. They acknowledged the findings. 3. Resident 1 was admitted to the facility in 06/2023 with diagnoses including congestive heart failure. Resident 1’s record was reviewed, including resident evaluations completed, and identified the following: * A resident evaluation was completed on 07/15/24. The evaluation revealed s/he smoked. * A smoking evaluation was completed on 07/27/24. On 11/20/24 Staff 1 (Administrator) was asked to provide the most recent quarterly evaluations for Resident 1. Staff 1 reported the evaluations listed above were the most recent. The need to ensure quarterly resident evaluations were completed, including smoking evaluations, was discussed with Staff 1, Staff 2 (Administrator in Training), and Staff 5 (RN) on 11/21/24. They acknowledged the findings. 4. Resident 3 was admitted to the facility in 04/2024 with diagnoses including chronic obstructive pulmonary disease (COPD) and chronic congestive heart failure. Resident 3’s record was reviewed, including resident evaluations completed, and identified the following: Review of the resident's quarterly evaluation, dated 09/12/24, and interviews with and observations of Resident 3 revealed s/he smoked. Resident 3's current smoking evaluation was requested on 11/19/24. Staff 1 (Administrator) reported there was no quarterly smoking evaluation completed for Resident 3. The most recent prior smoking evaluation was dated 07/08/24. The need to ensure quarterly evaluations were completed, including smoking evaluations, was discussed with Staff 1 (Administrator), Staff 2 (Administrator in Training), and Staff 5 (RN) on 11/21/24. They acknowledged the findings.

1. Res. 2 Evaluation has been updated to include : Pronouns, Gender Identity, and personality including hoe the res. copes with change of challenging situations. Res. 5 evaluation has been reviewed and updated to reflect the res. current needs and status. Res. 1 smoking evaluation has been completed. 2. A. All evaluation tools have been updated to include the required information. B. All res. will be reevaluated to ensure they reflect the res. current needs and status. C. All res. evaluations will be completed prior to res. move in, reviewed 30 days after and then updated 60 days after that date. They will all be reviewed and updated appropriately on a quarterly basis. This includes any sub assessments as well. 3. A. Daily- All upcoming evaluations will be reviewed at the daily clinical meeting. B. Monthly- QI team will review and report any outstanding assessments. 4. Admin/RCC/RN/Designee

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:

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 4 of 4 sampled residents (#s 1, 3, 4, and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 5 moved into the facility in 04/2016 and had diagnoses including diabetes and neuropathy. The resident's current service plan, dated 09/11/24, was reviewed, observations were made, and interviews were conducted. The service plan was not reflective of the resident's needs and preferences, and did not provide clear instruction to staff, in the following areas: * Toilet/hygiene assistance; * Standing assistance; * Upper body dressing; * Shower-specific instructions; and * Shoulder pain, including interventions. The need to ensure service plans were reflective of resident needs and preferences and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (Administrator in Training), and Staff 5 (RN), on 11/21/24. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 03/2024 with diagnoses including osteoarthritis. Observations, interviews, and review of the current service plan, dated 08/22/24, revealed the service plan was not reflective of the resident care needs and/or did not provide clear direction to staff in the following areas: * Shower assistance; * Toileting; and * Gait belt use. On 11/21/24, the need to ensure service plans were reflective of resident care needs and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (Administrator in Training), and Staff 5 (RN). They acknowledged the findings. 3. Resident 3 was admitted to the facility in 04/2024 with diagnoses including chronic obstructive pulmonary disease (COPD) and chronic congestive heart failure. Observations, interviews, and review of the current service plan, dated 09/12/24, revealed the service plan did not provide clear direction to staff and/or was not implemented in the following areas: * Abnormal Involuntary Movement Scale (AIMS) Assessment; and * Staff to re-evaluate smoking abilities every quarter. On 11/21/24, the need to ensure service plans provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (Administrator in Training), and Staff 5 (RN). They acknowledged the findings. 4. Resident 1 was admitted to the facility in 06/2023 with diagnoses including congestive heart failure, hypertension, atrial fibrillation, and major depressive disorder. The resident’s current service plan, dated 08/22/24, was reviewed, and interviews were conducted. The service plan was not implemented in the following areas: * Bathing, one-person assistance; * Abnormal Involuntary Movement Scale (AIMS) assessment quarterly; and * Staff to re-evaluate smoking abilities every quarter. The need to ensure service plans were implemented by staff was discussed with Staff 1 (Administrator), Staff 2 (Administrator in Training), and Staff 5 (RN), on 11/21/24. They acknowledged the findings.

1. A. Resident 5 service plan has been updated with clear direction to staff in the following areas: Toilet/hygiene assistance, standing assistance, upper body dressing, shower specific instructions and shoulder pain, including interventions. B. Resident 4 service plan has been updated with clear direction to staff in the following areas: Shower assistance, toileting and gait belt use. C. Resident 3 service plan has been updated with clear direction to staff in the following areas: Abnormal involuntary movement scale (AIMS) assessment and smoking abilities. D. Resident 1 service plan has been updated with clear direction to staff in the following areas: Bathing-1 person assist, Abnormal Involuntary Movement Scales (AIMS) assessment, smoking abilities. 2. A. Service Plans have been updated and reviewed to be person centered and include all required areas. Clear direction as to what the resident needs and preferences have been added. 3. A. Daily- All upcoming service plans will be reviewed at the daily clinical meeting. B. Monthly- QI team will review and report any outstanding service plans. 4. Admin/RCC/RN/Designee

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

OAR 411-054-0036 (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 service plans were developed by a Service Planning Team that consisted 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 provided services to the resident for 3 of 4 sampled residents (#s 1, 3, and 5) whose service plans were reviewed. Findings include, but are not limited to: Resident 1, 3, and 5's most recent service plans lacked documentation that a Service Planning Team reviewed and participated in the development of the service plans. On 11/21/24 the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Administrator), Staff 2 (Administrator in Training), and Staff 5 (RN). They acknowledged the findings.

1. All Service plans will include the resident, residents rep. if applicable, any person of the res. choice, the facility admin. or designee, and one other staff person familiar with or has provided services to the res. All members of the service plan team have signed acknowledgement of participation for res. 1, 3 & 5. 2. A. The service plan team meets weekly on Mondays. B. A schedule of service plan meetings has been developed for all res. C. Invitations for the upcoming month will be communicated to all res. by the 10th of the prior month. D. If a member of the res. service planning team is unable to attend, the service plan will be given to them for review with a request for input or proposed changes if applicable. E. If a res. rep or another member of the service planning team is unable to attend in person but attends electronically, participation will be noted on the service plan and or res. progress notes. 3. Weekly 4. Administrator/Designee/RCC

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:

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 resident-specific interventions were determined and documented for short-term changes of condition, were communicated to staff on each shift, and were monitored with progress noted at least weekly through resolution for 4 of 4 sampled residents (#s 1, 3, 4, and 5). Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 06/2023 with diagnoses including congestive heart failure, restless leg syndrome, hypertension, atrial fibrillation, and major depressive disorder. Resident 1’s 06/17/24 through 11/17/24 progress notes, weight records, and Interim Service Plans were reviewed, and the following was identified: a. There was no documented evidence the facility communicated the determined actions or interventions to staff on each shift and documented weekly progress through resolution for the following short-term change of condition: * 10/15/24: Medication error of unknown classification. b. There was no documented evidence the facility determined and documented what actions or interventions were needed for the resident, communicated the determined actions or interventions to staff on each shift, and documented weekly progress through resolution for the following short-term change of condition: * 07/2024: Significant weight loss of greater than five percent in one month. Refer to C280. The need to ensure actions and interventions for short-term changes of condition were determined and documented, communicated to staff on each shift, and the changes were monitored with weekly progress noted to resolution was discussed with Staff 1 (Administrator), Staff 2 (Administrator in Training), and Staff 5 (RN) on 11/21/24. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 03/2024 with diagnoses including osteoarthritis. Resident 4's 08/19/24 through 11/18/24 facility progress notes and Interim Service Plans (ISPs) were reviewed and showed the following changes of condition: * A progress note, dated 10/08/24, indicated the resident was being placed on alert for return from the hospital with a diagnosis of a hematoma to their right hip. There was no documented evidence the resident’s hematoma had resolved; * A progress note, dated 10/12/24, indicated the resident experienced a fall with a skin tear to his/her left thumb. There was no documented evidence of interventions to minimize the further occurrence of falls and when the skin tear had resolved; and * A progress note, dated 10/29/24, indicated the resident had two bumps and a scrape to his/her left shin. There was no documented evidence the bumps and scrape had resolved. On 11/21/24, the need to ensure residents who experienced a change of condition were monitored until resolution and there was documented evidence of interventions to minimize the further occurrence of falls was discussed with Staff 1 (Administrator), Staff 2 (Administrator in Training), and Staff 5 (RN). They acknowledged the findings. 3. Resident 5 moved into the facility in 04/2016 with diagnoses including diabetes and neuropathy. During the acuity interview on 11/18/24 staff reported Resident 5 had a fungal rash being treated by the facility. Resident 5's 08/18/24 through 11/18/24 facility progress notes and Interim Service Plans (ISPs) were reviewed and showed the following changes of condition: * Chronic fungal rash; and * Psoriasis on the ears. Staff 11 (CG), interviewed on 11/20/24 at 9:03 am, reported that the fungal rash was red, but no open areas were present at that time. Staff 11 reported MT staff applied cream to the resident’s ears daily for peeling skin. There was no documented evidence the skin conditions were monitored at least weekly through resolution. During an interview on 11/21/24, Staff 5 (RN) reported she had not documented weekly progress of the skin conditions but had been viewing them weekly. The need to ensure short-term changes of condition were monitored with weekly progress noted until resolution was reviewed with Staff 1 (Administrator), Staff 2 (Administrator in Training), and Staff 5 on 11/21/24. They acknowledged the findings. 4. Resident 3 was admitted to the facility in 04/2024 with diagnoses including chronic obstructive pulmonary disease (COPD) and chronic congestive heart failure. Resident 3's 08/18/24 through 11/18/24 facility progress notes and Interim Service Plans (ISPs) were reviewed and showed the following changes of condition: * Medication changes; * Antibiotic use; and * Low blood pressure. There was no documented evidence the changes of condition were monitored through resolution. On 11/21/24, the need to ensure residents who experienced a change of condition were monitored until resolution was discussed with Staff 1 (Administrator), Staff 2 (Administrator in Training), and Staff 5 (RN). They acknowledged the findings.

1. Specific interventions have been determined and documented for COC and have been communicated to staff. Evaluations have been completed and eval/SP updated with COC. A. Res. 1 Med error 10/15 has been investigated. Nutritional eval completed with interventions and communicated to MD/Res./Res. rep. B. Res. 4 Fall risk eval completed. Interventions added to res. eval/SP and communicated to MD/Res./Res. rep. Skin evaluation completed by LN and noted issues are presently resolved. C. Res. 5 has fungal rash treatment. Has been added to LN weekly skin rounds for monitoring. Reporting guidelines have been provided to res. TX record. D. Res. 3 LN completed re eval of res. for Medication changes, antibiotic use and low BP. The above areas have been resolved and documentation completed. 2. A. 24 hour book and components reviewed with all care staff. Alert charting system put in place. All care staff have been trained on proper use. B. Home health orders have been requested for all res. with ongoing skin issues that are not expected to resolve with minimal interventions. C. LN will complete weekly skin rounds and document findings in the new skin book now implemented. D. LN to communicate any interventions/monitoring guidelines to staff using the 24 hour book, alert charting and TSP/Change of service system implemented. 3. A. Daily- Will be reviewed at a daily clinical meeting. B. Monthly skin and weight meetings scheduled for the 3rd Thursday of every month. 4. Administrator/Designee/ LN/ RCC

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

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to assess residents who experienced a significant change of condition for 1 of 1 sampled resident (#1) who experienced weight loss. Findings include, but are not limited to: Resident 1 was admitted to the facility in 06/2023 with diagnoses including congestive heart failure and major depressive disorder. A review of the resident's clinical record, including progress notes and weight records dated 06/01/24 through 11/17/24 and service plan dated 08/22/24, was completed, and staff were interviewed. The following was identified: The resident’s weight was recorded as follows: * 06/2024 – 100.6 pounds; * 07/2024 – 94.6 pounds; * 08/2024 – 96.0 pounds; * 09/2024 – 94.0 pounds; * 10/2024 – 93.8 pounds; and * 11/2024 – 93.0 pounds. From 06/2024 to 07/2024 the resident lost six pounds, or 5.96% of his/her body weight, which constituted a significant weight loss and represented a significant change of condition. Review of the resident’s record revealed no documented evidence the weight loss was evaluated, the facility nurse was notified, the change was assessed by the RN, and the service plan was updated as needed as required for the significant weight loss. The resident was observed at two meals. S/he consumed 90% of the meals. S/he was observed to require no assistance for eating. On 11/20/24, survey requested a current weight for Resident 1. The resident refused to be weighed, and a current weight was unable to be obtained. During an interview on 11/20/24 at 1:30 pm, Staff 5 (RN) confirmed there was no documented evidence the required elements for the significant change of condition were completed. The need for the RN to assess residents who experienced a significant change of condition was discussed with Staff 1 (Administrator), Staff 2 (Administrator in Training), and Staff 5 (RN) on 11/21/24. They acknowledged the findings.

1. Res. 1 has been assessed by RN for weight loss. COC completed. Res. 1 on weekly weights, and reviewed by LN. Outcomes will continue to be communicated to MD. 2. Weight program has been implemented. Monthly weights are to be completed by the 10th of each month. Monthly weight meetings will be held to review any concerns the 3rd Thursday of each month. Weight meetings will include: LN/RN, Admin./Designee, RCC and dietary manager. All interventions will be documented to res. eval/SP & communicated to res./res. rep, MD, care staff, dietary dept. 3. Weekly per MD order, Monthly at weight meetings. 4. Administrator/Designee/RN/RCC

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

OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(B) Delegation and Teaching. Delegation and teaching must be provided and documented by a RN in accordance with the Oregon Administrative Rules adopted by the Oregon State Board of Nursing in chapter 851, division 047. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care were completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules for 1 of 1 sampled resident (# 5) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to: According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task, and observation and evaluation of the staff-demonstrated task. During the acuity interview on 11/18/24, it was identified that Resident 5 received insulin injections by unlicensed (MT) staff daily. Review of Resident 5's delegation documentation and diabetic administration records from 10/01/24 through 11/18/24 revealed the following: There was no documented evidence Staff 14 (MT) had been delegated to administer insulin to Resident 5 until 11/18/24. The delegation reviews for Staff 1 (Administrator), dated 04/12/24, and Staff 15 (MT), all dated 04/17/24 and completed by a previous facility RN, did not have a documented periodic inspection/evaluation. On 11/18/24, Staff 5 (RN) delegated Staff 1, 14, and 15 to administer insulin to Resident 5. In an interview on 11/18/24, Staff 3 (RN) reported she had not been fully trained on the delegation process but had been observing the MT staff administer insulin and was providing education with competency tests prior to the 11/18/24 delegations being completed. The delegation reviews for Staff 1, Staff 14, and Staff 15, dated 11/18/24, lacked the following documentation: * Prior to delegating, the RN did not ensure policies were available to support RN engagement in the delegation process; * The RN's determination that the client's condition was stable and predictable; * The client did not require assessment during the procedure; * The procedure did not require interpretation or independent decision-making; * The procedure was reasonably predictable; * The procedure was not life-threatening and delegation posed minimal risk to the client; * The environment of care supported the safe performance of the nursing procedure; and * The RN had the appropriate resources necessary to fulfill nursing practice and delegation responsibilities, including availability to provide assessment of the resident and ongoing competency validation of the unregulated assistive person’s (UAP’s) performance. After provision of procedural guidance and initial direction, the RN failed to complete the following: * Evaluate and validate the UAP’s performance of the nursing procedure; * Address questions the UAP and resident may have had; and * Amend documented instructions if needed. After the RN validated the UAP’s accurate performance, the RN failed to document the clinical judgement used to determine the authorization period based on evaluation of data, including, but not limited to, the following: * Nursing procedure delegated; * Length of time the RN had worked with the UAP; * Frequency the client should be reassessed based on the assessed baseline; and * Health problems that may impact the resident’s condition related to the delegated nursing procedure. The need to ensure staff who administered insulin injections were appropriately delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1 (Administrator) and Staff 5 on 11/21/24. They acknowledged the findings.

1. Delegation & Supervision of special tasks of nursing care will be completed in accordance with the OSBN rules, who receive insulin injections by unlicensed staff. Staff 14 has been delegated to administer insulin for res. 5 as of 11/18/2024. Staff 3, RN has been to the Role of the Nurse class, attended delegation class & has received one on one training with NWSS RN Consultant on 12/14/2024. 2. Delegation binder has been implemented. All res. have been identified and staff have been individually delegated approp. per the OSBN guidelines. 3. The QI team will audit and monitor delegation documents monthly for the next 6 months to ensure compliance. 4. Administrator/Designee & RN.

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

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to establish and maintain effective infection prevention and control for protocols to provide a safe, sanitary, and comfortable environment and have an "Infection Control Specialist" qualified by education, training and experience or certification. Findings include, but are not limited to: a. Upon entrance to the facility on 11/18/24, the facility's designated "Infection Control Specialist" and documentation of completed specialized training in infection prevention was requested. On 11/18/24, Staff 1 (Administrator) acknowledged the facility did not have a designated “Infection Control Specialist”. b. Observations made from 11/18/24 to 11/21/24 revealed the following: * Multiple universal caregivers served food without donning a protective barrier over potentially contaminated clothing. The need to ensure establishment and maintenance of infection prevention control protocols and compliance with the facility's designated "Infection Control Specialist" qualification and the need to ensure universal precautions for infection control were exercised while serving meals to the residents was discussed with Staff 1, Staff 2 (Administrator in Training) and Staff 5 (RN) and on 11/21/24. They acknowledged the findings.

1. a. The administrator and RCC both took the 4 hour Infection Prevention and Control class from Oregon Care Partners. The designated "Infection Control Specialist" will be the administrator, but for back up when Administrator is unavailable the RCC will be designated. b. All staff was educated regarding the need for wearing aprons when serving food, and reeducated on proper infection control when serving meals. 16 aprons were purchased so that there would be a clean apron for every caregiver for each meal. NOC will wash the apron every night. 2. Infection control specialist will do routine infection control audits during meal times and do education on the spot with staff that are not following proper infection practices. Infection control specialist will submit the audits to the CQI team when completed for review. 3. Infection Control specialist will audit weekly (rotating meal times) x4 week, and on an ongiong basis at minimum of quarterly. These audit reports will be submitted to CQI committee on a regular basis. 4. The administrator or designee will be responsible for getting the building into compliance and maintaining compliance going forward.

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

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments (1) MEDICATION AND TREATMENT ADMINISTRATION SYSTEMS. The facility must have safe medication and treatment administration systems in place that are approved by a pharmacist consultant, registered nurse, or physician.(a) The administrator is responsible for ensuring adequate professional oversight of the medication and treatment administration system. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight of the medication and treatment administration systems. Findings include, but are not limited to: Administrative oversight of the medication and treatment administration system was found to be ineffective. Refer to deficiencies in the following areas: C282: RN Delegation and Teaching; C302: Systems: Tracking Control Substances; C310: Systems: Medication Administration; C320: Systems: Medication & Treatment-General; and C325: Systems: Self-Administration of Medication. On 11/21/24, the need to ensure the facility had a safe medication system with professional oversight was discussed with Staff 1 (Administrator), Staff 2 (Administrator in Training), and Staff 5 (RN). They acknowledged the findings.

1. Facility has implemented a safe medication system and has adequate oversight of the medications and treatments of the administration system. 2. C282- Delegation and teaching will be completed and documented as required. C302- Control substance tracking system in place. C320 Medication & Treatments, System implemented , C325 Systems, self med admin; all res. who self admin. med/treatments have been eval with eval/SP updated with results. 3. A. Daily review at clinical meeting- Will review 24 hour report, will review Emar dashboard for new orders, admin. records review. Triple check system for order accuracy implemented. B. Monthly QI review for med errors, delegation system. C. Quarterly self med evals will be reviewed and updated as needed. 4. Administrator/Designee

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments (1) MEDICATION AND TREATMENT ADMINISTRATION SYSTEMS. The facility must have safe medication and treatment administration systems in place that are approved by a pharmacist consultant, registered nurse, or physician.(a) The administrator is responsible for ensuring adequate professional oversight of the medication and treatment administration system. This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 2 sampled residents (#1) who were administered scheduled and as needed narcotic medications. Findings include, but are not limited to: Resident 1 was admitted to the facility in 06/2023 with diagnoses including congestive heart failure and restless leg syndrome. The resident’s current prescriber orders dated 10/04/24 were reviewed and revealed: * Resident 1 had a physician order for oxycodone-acetaminophen 7.5-325 mg, give 1 tablet by mouth as needed for pain two hours apart from the scheduled dose. Review of Resident 1’s 11/01/24 through 11/18/24 MAR and narcotic log revealed the following: * There were three occasions from 11/01/24 through 11/18/24 when staff signed the narcotic log that the PRN oxycodone/acetaminophen was removed from the drug card, however, staff failed to initial and document on the MAR the resident was administered the PRN medication. Inconsistencies between the narcotic log and the 11/2024 MAR were reviewed with Staff 1 (Administrator), Staff 2 (Administrator in Training), and Staff 5 (RN) on 11/21/24. They acknowledged the discrepancies and findings.

1. Facility has a system in place for accurately tracking controlled substances. Res. 1 PRN parameters reviewed. Med error investigated. Med tech is trained to document approp. in MAR & Narc count log. 2. A. A MAR to PO review of all orders has been completed. B. A MAR to cart audit will be completed. C. Triple check system implemented for order accuracy. All med techs have been trained to properly count at shift change. 3. Daily- Emar to be reviewed daily at clinical meetings. PRN administored medications will be reviewed for approp. documentation. Admin./RCC/LN attend cross over unannounced to spot check for compliance and report findings for review at monthly QI meetings. 4. Administrator/Designee

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

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate and provided clear instruction and parameters for administration of PRN medications for 2 of 4 sampled residents (#s 4, and 5) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 03/2024 with diagnoses including gastro-esophageal reflux disease. Review of Resident 4's 11/01/24 through 11/18/24 MAR/TAR, identified the following: * Resident was prescribed PRN acetaminophen 650 mg every four hours as needed for pain and PRN hydrocodone-acetaminophen 5-325mg every eight hours as needed for pain. There were no directions for unlicensed staff on which PRN pain medication to administer first. * Resident was prescribed PRN fleet enema 7-19 GM/118 ML every 24 hours as needed for constipation and PRN Milk of magnesia 1200MG/15ML every 24 hours for constipation. There were no directions for unlicensed staff on which PRN pain medication to administer first. On 11/21/24, the need to ensure there were clear parameters for unlicensed staff when administering medications was discussed with Staff 1 (Administrator), Staff 2 (Administrator in Training), and Staff 5 (RN). They acknowledged the findings. 2. Resident 5 was admitted to the facility in 04/2016 with diagnoses including type two diabetes and congestive heart failure. The resident's 10/1/24 through 11/18/24 Diabetic Administration Record (DAR) and current physician orders were reviewed and revealed the following: The physician orders stated the resident was to receive Ozempic 2mg subcutaneous injection in the morning every Thursday for type two diabetes. The DAR listed Staff 14 (MT) as having administered the Ozempic injection on four of the five scheduled weekly administration dates and was blank for the 11/17/24 administration date. During interviews with Staff 5 (RN) and Staff 14 during survey, both reported that although Staff 14 was initialing the medication record as having administered the Ozempic weekly, Staff 5 was administering the medication on each of the scheduled days. Staff 5 stated that she had also administered the medication on 11/17/24 and acknowledged the lack of initials on the DAR. Resident 5 during interview on 11/20/24 stated the RN had been administering the Ozempic weekly. The medication administration record (DAR) was inaccurate, as the person who initialed for the administration of the Ozempic was not the person that administered the medication. The need for accurate records was discussed with Staff 1(Administrator), Staff 2 (Administrator in Training), and Staff 5 (RN) on 11/21/24. They acknowledged the findings.

1. The facility has a medication administration system implemented to provide clear instruction & parameters for admin. of PRN medications. A. Res. 4 MAR has been updated to include clear instruction and parameters added for PRN admin. of acetaminophen first, if not resolved, proceed to admin. of hydrocodone-acetaminophen. B. Res. 5 DAR has been updated to receive Ozempic 2mg every Thursday. RN has delegated the task to the med tech to complete and document approp. 2. Review of all PO's and MAR completed. Medication parameters have been added for all PRN medications. This included res. who receive multiple medications for the same issue, and which to admin. first. MAR has been updated if res. is able to self direct, or if the med tech is to use a pain scale or other directive from LN/MD. 3. Daily review at clinical meeting. All PRN medication admin. will be reviewed for proper admin./documentation. 4. Administrator/designee/RCC/RN

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by:

OAR 411-054-0055 (4) Systems: Medication & Treatment-General (4) MEDICATION AND TREATMENT - GENERAL. The facility must maintain legible signatures of staff that administer medications and treatments, either on the MAR or on a separate signature page, filed with the MAR.(a) If the facility administers or assists a resident with medication, all medication obtained through a pharmacy must be clearly labeled with the pharmacist's label, in the original container, in accordance with the facility's established medication delivery system.(b) The facility shall ensure that prescription drugs dispensed to residents are packaged in a manner that reduces errors in the tracking and administration of the drugs, including, but not limited to, the use of unit dose systems or blister packs.(A) The facility shall have as its primary goal dispensing prescription drugs in unit dose systems, blister packs or similar packaging.(B) When unit dose packaging cannot be reasonably achieved, the facility shall have a written policy describing how prescription drugs that are not prepared as unit dose or blister packs shall be dispensed. Written policies shall be in effect not later than October 1, 2018.(C) Subsection (b) of this rule does not apply to residents receiving pharmacy benefits through the United States Department of Veterans Affairs, if the pharmacy benefits do not reimburse cost of such packaging.(c) Over-the-counter medication or samples of medications must have the original manufacturer's labels if the facility administers or assists a resident with medication.(d) All medications administered by the facility must be stored in locked containers in a secured environment such as a medication room or medication cart.(e) Medications that have to be refrigerated must be stored at the appropriate temperature in a locked, secure location.(f) Order changes obtained by telephone must be documented in the resident's record and the MAR must be updated prior to administering the new medication stated on the order. Telephone orders must be followed-up with written, signed orders.(g) The facility must not require residents to purchase prescriptions from a pharmacy that contracts with the facility. This Rule is not met as evidenced by: Based on interview, and record review, it was determined the facility failed to maintain legible signatures of staff who administered medications and treatments, either on the MAR or on a separate signature page, filed with the MAR for 4 of 4 sampled residents (#s 1, 3, 4 and 5) whose MARs were reviewed. Findings include, but are not limited to: A review of Resident 1, 3, 4 and 5's 11/01/24 through 11/18/24 medication and treatment administration records revealed there were no documented signatures to identify which staff administered medications and treatments. The need to ensure the facility maintained legible signatures of staff who administer medications and treatments, either on the MAR or on a separate signature page filed with the MAR, was discussed with Staff 1 (Administrator), Staff 2 (Administrator in Training), and Staff 5 (RN) on 11/21/24. They acknowledged the findings.

1. The facility has a separate signature page to maintain legal signatures of staff who have administered medications & treatments. 2. Res. 1, 3, 4 & 5 as well as all res. have documentation of signatures for med techs/LN that has admin. medications/treatments. 3. A new signature page will be made each month at time of cycle fill. The signature page will also be updated with all new hires. 4. Administrator/designee/RCC.

OAR 411-054-0055 (4) Systems: Medication & Treatment-General (4) MEDICATION AND TREATMENT - GENERAL. The facility must maintain legible signatures of staff that administer medications and treatments, either on the MAR or on a separate signature page, filed with the MAR.(a) If the facility administers or assists a resident with medication, all medication obtained through a pharmacy must be clearly labeled with the pharmacist's label, in the original container, in accordance with the facility's established medication delivery system.(b) The facility shall ensure that prescription drugs dispensed to residents are packaged in a manner that reduces errors in the tracking and administration of the drugs, including, but not limited to, the use of unit dose systems or blister packs.(A) The facility shall have as its primary goal dispensing prescription drugs in unit dose systems, blister packs or similar packaging.(B) When unit dose packaging cannot be reasonably achieved, the facility shall have a written policy describing how prescription drugs that are not prepared as unit dose or blister packs shall be dispensed. Written policies shall be in effect not later than October 1, 2018.(C) Subsection (b) of this rule does not apply to residents receiving pharmacy benefits through the United States Department of Veterans Affairs, if the pharmacy benefits do not reimburse cost of such packaging.(c) Over-the-counter medication or samples of medications must have the original manufacturer's labels if the facility administers or assists a resident with medication.(d) All medications administered by the facility must be stored in locked containers in a secured environment such as a medication room or medication cart.(e) Medications that have to be refrigerated must be stored at the appropriate temperature in a locked, secure location.(f) Order changes obtained by telephone must be documented in the resident's record and the MAR must be updated prior to administering the new medication stated on the order. Telephone orders must be followed-up with written, signed orders.(g) The facility must not require residents to purchase prescriptions from a pharmacy that contracts with the facility. This Rule is not met as evidenced by:

OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure residents who self-administered their medications were evaluated upon move-in and at least quarterly thereafter to ensure the residents' ability to safely self-administer medications for 2 of 2 sampled residents (# 2 and 3). Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 04/2024 with diagnoses including chronic obstructive pulmonary disease (COPD), and chronic congestive heart failure. During the acuity interview on 11/18/24, Resident 3 was not identified as self-administering any of his/her medications. However, there was a signed physician order for self-medication administration and review of Resident 3's MAR on 11/18/24 revealed s/he was self-administering a nebulizer compressor with nebulizer medication and an albuterol inhaler. Review of Resident 3's medical records revealed there was no documented evaluation of Resident 3's ability to safely self-administer medications. On 11/18/24, Staff 1 (Administrator) was unable to locate a copy of the self-administration evaluation. The need to ensure residents who chose to self-administer their medications were evaluated at least quarterly to assure the residents' ability to safely self-administer medications was reviewed with Staff 1, Staff 2 (Administrator in Training), and Staff 5 (RN) on 11/21/24. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 11/2024 with diagnoses of congestive heart failure. During acuity interview on 11/18/24, Staff 1 (Administrator) reported that Resident 2 self-administered all his/her medications. There was a signed physicians order for self-medication administration and the service plan was reflective, although there was no documented evidence a self-medication evaluation had been completed by the facility. On 11/20/24 Staff 1 reported she was unable to locate a self-medication evaluation for Resident 2. The need to ensure a self-medication administration evaluation was completed for each resident who wished to self-administer medications was discussed with Staff 1, Staff 2 (Administrator in Training), and Staff 5 (RN) on 11/21/24. They acknowledged the findings.

1. The facility has evaluated all residents who self administer medications. Evaluations and SP's have been updated with results for: Res. 3 for nebulizer compressor/medication and albuterol inhaler. Res. 2 self med eval completed for all res. medications, 2. A. All PO's have been reviewed. Res. with an order to self admin. have had an eval completed with results updated on res. eval./SP. B. Facility walk through of all residents units completed. All res. who are identified to have medications in apt. have had a self med eval completed, with eval/SP updated. C. Res. who need a self med eval completed will be discussed at the weekly care team meeting. Self med evals will be completed prior to move in, eval updated quarterly or sooner if a COC occurs. 3. Daily review at clinical meeting, new MI review, Weekly care plan meeting. Monthly - QI team to review all new move-ins. 4. Administrator/designee/ RCC/LN

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

OAR 411-054-0037 (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 have an accurate number of care minutes included on the acuity-based staffing tool (ABST) for each of the 22 care areas for 2 of 4 sampled residents (#s 1 and 5). Findings include but are not limited to: 1. A review of Resident 5’s ABST record showed the resident required zero minutes in the following care areas: * Transferring in and out of chair; and * Assistance with bowel and bladder management. During interview with Resident 5 on 11/18/24, the resident reported that staff assist him/her in the bathroom with peri-hygiene, and there were mornings when assistance was needed to stand from the recliner chair. Staff 11 (CG) reported during an interview on 11/20/24 at 9:00 am, the resident called for staff assist when using the bathroom daily for hygiene assistance and needed assist to stand up from the recliner on many mornings due to leg pain and stiffness. On 11/21/24 at approximately 1:00 pm, the surveyor reviewed the resident’s ABST record findings with Staff 1 (Administrator), Staff 2 (Administrator in Training) and Staff 5 (RN) to include the requirements of the ABST. They acknowledged the findings. 2. A review of Resident 1’s ABST record showed the resident required zero minutes on the following care areas: * Responding to call lights; * Monitoring physical conditions or symptoms; and * Grooming, such as nail care and brushing hair. Staff 8 (CG) stated during an interview on 11/20/24 at 11:18 am, the resident used the call light for staff assistance several times daily. The 08/22/24 service plan indicated the resident’s weight and vital signs were checked weekly, and nail and foot care were provided twice monthly. On 11/21/24 at 1:24 pm, the ABST record findings and requirements of the ABST were reviewed with Staff 1 (Administrator), Staff 2 (Administrator in Training), and Staff 5 (RN). They acknowledged the findings.

1. Resident care plan for residents 1 and 5 have been updated to correctly reflect the individualized care plan, so that we have an accurate accounting in ABST. Then the ABST is reflective of any of those changes. 2. Going forward at each Quarterly review, the ABST will be updated to reflect the updated Quarterly care plan approved and worked on by IDT Service Plan team. The resident's ABST will be opened and closed each quarter so that every resident is updated at minimal of quarterly to meet OAR requirement. 3. The ABST review report will be printed monthly and given to the CQI team for review. If any trends or concerns are identified then CQI will pull them into a PIP to get them into and maintain compliance. 4. Administrator or designee will be responsible for getting into and maintaining complaince going forward.

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:

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure all residents had an ABST evaluation that was updated quarterly and 1 of 1 sampled resident (#2) had an ABST evaluation completed upon admission. Findings include, but are not limited to: Review of the facility’s ABST on 11/20/24 revealed there was no documented evidence of: * An updated quarterly ABST evaluation for two unsampled residents; and * An ABST evaluation completed upon admission for Resident 2 who admitted 11/05/24. On 11/21/24, the need to ensure all resident ABST evaluations were updated no less than quarterly to correspond with the quarterly service plan and were entered upon admission was discussed with Staff 1 (Administrator). She acknowledged the findings.

1. The resident #2 was added to ABST. ABST will be updated minimally of quarterly when each residents care plan, care conference meeting is completed. The ABST will be reflective of the time required for the staff to be able to complate all care based on the person center care plans. 2. Each time a resident has a care conference and quarterly review and update of care plan, the designee responsible for the ABST will make sure that it is updated. 3. The ABST report with update dates will be submitted to CQI at the meetings. The campus Administartor or designee will audit the ABST updates, etc monthly x 3 months, and then 2X quarterly, and then as needed to make sure compliane is maintained. The CQI committee will also review the submitted information and if there are any concerns or trends, will immediately pull those concerns into a PIP and address with CQI process. 4. The administrator or designee will be responsible for getting the ABST within complaince and then complaince maintained going forward.

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

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct-care staff (#s 10, 14 and 16) demonstrated satisfactory competency in all assigned duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 11/20/24. The following were identified: Staff 10 (MT) hired 6/13/24, Staff 14 (MT), hired 05/30/24, and Staff 16 (CG) hired 08/09/24, all lacked documented evidence of demonstrated satisfactory competency in the following required areas within 30 days of hire: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment, observation, and reporting; * General food safety, serving and sanitation; and * Other duties as applicable (Med pass, treatments). On 11/19/24, Staff 1 (Administrator) reported the competency check lists for the requested newly hired staff were not available. The need to ensure newly hired staff completed training and demonstrated competency in all assigned duties within 30 days of hire was discussed with Staff 1, Staff 2 (Administrator in Training), and Staff 5 (RN) on 11/21/24. They acknowledged the findings.

1. a. All staff will be brought into complaince with all mandatory training. This will be done in a combination of all staff meetings, Relias, and Oregon Care Partners. b. All staff will be given and do return demonstration competency. Then they will complete compentencies at each annual review based on date of hire. 2. Each new hire will be required to complete all required preservice trainings, compentencies, and eduation prior to being scheduled to work on the floor. These files will be kept in the Administrator's office. 3. All employee education will be audited monthly for annual anniversary dates, completion of required classes and compentencies. This audit will be sent to CQI. 4. Administrator or designee will be responsible for getting all compentencies and education in complaince and then maintaining compliance going forward.

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

OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff (6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF. (a) Annual infectious disease training requires the following: (A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training. (B) Annual in-service training must be documented in the employee record. (b) Biennial LGBTQIA2S+ training requires the following: (A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff. (i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite. (ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. (vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state. (D) The proposal for training submitted by a facility, entity, or individual shall include: (i) The regulatory criteria described in paragraph (C) of this section as part of the proposal. (ii) The following elements must be included in the proposal: (I) A statement of the qualifications and training experience of the facility, individual or entity providing the training; (II) The proposed methodology for providing the training either online or in person. (III) An outline of the training. (IV) Copies of the materials to be used in the training. (iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision. (c) Annual Home and Community-Based Services (HCBS) training requires the following: (A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations. (B) Annual in-service training must be documented in the employee record. (C) These annual trainings will be required as of April 1, 2025. (7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF. (a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire. (b) Requirements for annual in-service dementia training: (A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care. (B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter. (C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above. (D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia. (E) The facility shall determine the competency of direct care staff in dementia care in the following ways: (i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19). (ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff. (iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency. (8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure and document 2 of 3 long-term staff (#s 7 and 12) completed 12 hours of annual in-service training, including at least six hours of dementia care and one hour of infectious disease training, and failed to ensure 1 of 2 long-term non-care staff (# 6) completed infectious disease training. Findings include, but are not limited to: Staff training records were reviewed on 11/20/24 and revealed the following: a. There was no documented evidence Staff 7 (RCC) and Staff 12 (CG), hired 08/22/19 and 04/27/18 respectively, completed at least 12 hours of training related to the provision of care in CBC annually, including a minimum of six hours of training on dementia care topics and at last one hour of infectious disease training. b. There was no documented evidence Staff 6 (Life Enrichment Director) hired 01/05/23, completed infectious disease training annually as required. c. There was no documented evidence the facility designated two employees, one who represented management and one who represented direct care staff for LGBTQIA2S+ training. The need to ensure and document that long-term direct care staff completed the required number of hours of annual in-service training, long-term non-care staff completed annual infectious disease training and two employees were designated for LGBTQIA2S+ training was discussed with Staff 1 (Administrator), Staff 2 (Administrator in Training), and Staff 5 (RN) on 11/21/24. They acknowledged the findings.

1. All staff will be assigned either Oregon Care Partners or Relias classes that includes all classes meeting the requirements for the 12 hours of ongoing annual education. There will be a monthly all staff meeting, that will have a spedific focus for the month, and staff will be required to turn in the certificate of completion for the focus of the month. If those are not completed then the staff will be pulled from the floor schedule until all education requirements have been met prior to the end of each month. 2. Administrator has created a training spreadsheet and binder that will house all the completed educations, compentencies, and signed all staff meeting agendas. There will be a monthly audit that will be submitted to CQI. 3. The education binder will be audited quarterly for annual compentencies and monthly for educations. Any staff that do not have the required information will be pulled from the schedule until completion verification has been supplied. 4. Administrator or designee.

OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff (6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF. (a) Annual infectious disease training requires the following: (A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training. (B) Annual in-service training must be documented in the employee record. (b) Biennial LGBTQIA2S+ training requires the following: (A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff. (i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite. (ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. (vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state. (D) The proposal for training submitted by a facility, entity, or individual shall include: (i) The regulatory criteria described in paragraph (C) of this section as part of the proposal. (ii) The following elements must be included in the proposal: (I) A statement of the qualifications and training experience of the facility, individual or entity providing the training; (II) The proposed methodology for providing the training either online or in person. (III) An outline of the training. (IV) Copies of the materials to be used in the training. (iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision. (c) Annual Home and Community-Based Services (HCBS) training requires the following: (A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations. (B) Annual in-service training must be documented in the employee record. (C) These annual trainings will be required as of April 1, 2025. (7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF. (a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire. (b) Requirements for annual in-service dementia training: (A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care. (B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter. (C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above. (D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia. (E) The facility shall determine the competency of direct care staff in dementia care in the following ways: (i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19). (ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff. (iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency. (8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process. This Rule is not met as evidenced by:

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to conduct fire drills in accordance with the Oregon Fire Code and to provide fire and life safety instruction on alternate months. Findings include, but are not limited to: On 11/19/24, fire and life safety records dated between 06/2024 and 11/2024, were reviewed. The following was identified: a. Fire drill documentation failed to address the following: * Escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; * Number of occupants evacuated; and * Evidence alternate routes were used. b. There was no documented evidence the facility provided fire and life safety training to staff on alternating months from fire drills. The need to ensure fire drills were conducted in accordance with the Oregon Fire Code and fire and life safety instruction was provided to staff on alternate months was discussed with Staff 1 (Administrator), Staff 2 (Administrator in Training), and Staff 5 (RN) on 11/21/24. They acknowledged the findings.

1. The maintenance director or designee has obtained the updated form. A fire drill will be completed per OAR regulations. The new form will include Escape route used, problems encountered and those problems were resolved, comments relating to residents who resisted or failed to participate in the drill (the education provided to those residents on what to do if this was an actual emergency), number of oocupants evacuated, and show a map of the alernate routes used. 2. Maintenance director or designee has put together a calendar of the fire and life safety topics that they will be covering with staff on the off months of the scheduled fires drill. These items are all put into TELS so that the reminders and subjects will be given to Maintenance to perform the meetings or drills depending on the month of the year. Fire drills will be provided in the alternate months of the trainings in a routing shift schedule so that they are completed at different times of the day. The schedule of Fire Drills will be put into TELS so that the maintenance director or designee is making sure that the rotating schedule is meeting the requirement of hitting all shifts with drills per OAR. 3. The monthly education/firedrills will be submitted to the CQI at their meetings. CQI will be reviewing the minutes to make sure that all OAR requirements are met on the fire drills, as well as, verifying and seeing if there is any trends or issues with the schedule and education in the off months of the drils. The Campus administrator or designee will be auditing the schedule and verify it is getting completed per TELS schedule each month and reviewing the documentation to see if there is any additional education needed for the residents or staff in regards to evacuation or other problems that are documented from the active fire drills. 4. The Maintenance Director or designee is responsible for making getting into the compliance with drills and training. They are also responsible to ensure the drills, education, and life safety schedule is completed per OAR and TELS requirements to remain in complaince.

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

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents were instructed on fire and life safety procedures within 24 hours of admission and re-instructed at least annually. Findings include, but are not limited to: On 11/19/24, fire and life safety records were reviewed, and the following was identified: * There was no documented evidence of instruction to residents within 24 hours of admission on general safety procedures, evacuation methods, responsibilities during a fire, and designated meeting places inside or outside the building in the event of an actual fire; and * There was no documented evidence of fire and life safety training provided to residents at least annually. During an interview on 11/19/24 at approximately 1:00 pm, Staff 1 (Administrator) reported residents had not been receiving fire and life safety training on admission, nor had the facility been re-instructing residents at least annually. The need to ensure residents received fire and life safety training within 24 hours of admission and at least annually was discussed with Staff 1, Staff 2 (Administrator in Training), and Staff 5 (RN) on 11/21/24. They acknowledged the findings.

1. Maintenance manger or designee will hold a meeting with all residents to instruct them on fire safety, general safety procedures, evacauation methods, responsibility during fire drills, and designated meeting areas outside the building or within the fire safe area in the event of an actual fire. During the meeting each resident will handed a laminated evacuation route to have to keep in their rooms. We will also talk with the residents about the various shift fire drills every month, and their requirements as residents to participate. This will also give the residents a chance to ask any questions or for clarification on any of our evaucation, safety policies or procedures that they may not fully understand. We will take the time needed to makes the residents are comfortable with their roles in case of an emergency. The administrator or RCC will go over the emergency procedures, give the new admit a copy of the evacuation plan for their section of the building, and answer any questions the new admission might have regarding safety and evacuation. 2. Maintenance Manager will make sure that the annual training is put into TELS, as a required task every quarter. That way all residents will have the training annually, and if some of the residents can't attend one of them, there will another meeting available to them to learn the information needed and have an understanding of what to do in an emergency. The education for the safety meeting upon admit will be added the admission welcome packet, so that all new residents receive the required training within 24 hours of admit. This item will be added the admission checklist. 3. The meeting minutes and signatures will be submitted to CQI after completion of the all resident meetings and CQI will review the minutes and see if there are any trends that need to be addressed by PIP. Administrator will audit each new admission checklist to make sure that each and every admit receives the safety information timely. The admission checklist audit will submitted to CQI at the following meeting. 4. Maintenance Manager or designee is responsible for scheduling, leading, and providing the necessary information to the residents to get and remain in complaince with the OARs. Administrator or designee is responsible for making the information is included in the admission packet and recviewed with each and every resident within 24 hours. They are also responsible for maintaining compliance with the 24 safety information regulation.

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

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the interior and exterior environment were kept clean and in good repair. Findings include, but are not limited to: On 11/18/24, the interior and exterior of the facility was toured, and the following areas were identified in need of cleaning and/or repair: a. Exterior: * Multiple areas of the exterior siding around the perimeter of the building and courtyard had dirt, stains, and cobwebs; * Multiple areas of exterior siding and trim pieces of the building and courtyard were damaged and worn to bare wood; * Multiple exterior window screens were frayed and torn; * Multiple courtyard chairs were torn; and * The east courtyard was observed with a large sheet of black plastic covering a wall and window of the building. Behind the plastic sheet was missing siding and exposed insulation and missing siding. b. Interior: * Multiple wood chairs throughout the facility in hallways and the dining had scuffs, scrapes, and worn off finishes; * Multiple dining area tables had scuffs, scrapes, and worn off finishes; * Multiple interior walls, baseboards, doors, and door frames throughout the facility were dinged, chipped, gouged, scraped; * Skylight windows with cracks; and * A popcorn machine in the TV area was observed with a buildup of grease and debris. On 11/19/24, the interior and exterior areas in need of cleaning and/or repair were discussed with Staff 1 (Administrator) and Staff 3 (Maintenance Director). They acknowledged the findings.

1. a. Exterior Siding - We have a contracted to have the entire building pressure washed to remove all the moss, dirt, stains, and cobwebs on the exterior of the building. They will be doing this prior to painting the exterior of the building. b. Exterior Siding and Trim damaged wood. This wood will be replaced as needed, caulked, sealed and painted to meet the OAR requirements of homelike enviroment, in good repair. c. Multiple exterior screen. These screens have will be replaced with screens that are in good repair. d. Mulitple Court Yard chairs with tears. We have disposed of these chairs, and will replace with chairs in good repair by May of 2025. e. The east courtyard we have replaced the missing siding, covered the exposed insulation,and repaired the exterior wall. f. We are working with Directy Supply to replace all dining room chairs. We will also replace chairs as needed throughout the seating area. g. Dining room tables will be taken outside and painted or repaired. If they are unable to be repaired then we will replace the tables with new ones or replace the bases as needed. h. Multiple interior walls, baseboard, doors, door frames, and handrails have had the holes and gouges filled in and repainted throughout the building. i. Skylight windows we have a contractor who will be coming in and repairing the spot in the ceiling and getting rid of the cracked skylight. This will be completed by j. Education was provided with the activity director on the requirements, maintenance, cleaning, and putting away of the popcorn machine after every use. Popcorn machine was cleaned immediately, and will be maintained as clean after each use and not left out with popcorn, grease, and other things at anytime. 2. The areas on the exterior of the building, the furniture, the popcorn machine, the wall, doors, and handrails will be inspected on a monthly basis by the Maintenance director/administrator and/or designee/ This has been put in as a preventative maintenance task in TELS. The maintenance team will immedately fix, repair, and repaint as needed to maintain the building exterior and interior in good repair. The popcorn machine will not be left out in the TV area when not actively having a movie activity or serving popcorn. The cleaning of the popcorn machine will be put on a checklist to make sure that is is being cleaned after every use. 3. There will be an environemental checklist that will need to be completed monthly x3 months, and then quarterly therafter. This checklist will be presented to CQI, and they will monitor if there are any issues or trends identified. If there are ongoing issues CQI will pull this issues into a PIP and address through the CQI processes to aide in maintaining compliance for the interior and exterior of the building for homelike environment and good repair. 4. Maintenance Director or designee will be responsible for making sure the contractors complete the items based on their quotes and bring everything in compliance. Then once compliance is achieved, it will be the responsiblitu of the maintenance director or designee to monitor and maintain ongoing compliance.

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

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 provide security and to alert staff when residents exited the building. Findings include, but are not limited to: During the survey, multiple exit doors from the RCF and to the outside courtyards, were observed and failed to have a working alarm or other acceptable system to alert staff when residents left the building. On 11/19/24, Staff 1 (Administrator) indicated she was unaware courtyard doors needed an alarm or other acceptable system to alert staff. On 11/19/24, the need to ensure all exterior door and courtyard doors had a working alarm device or other acceptable system was discussed with Staff 1 (Administrator) and Staff 3 (Maintenance Director). They acknowledged the findings.

1. Exit Door Alarms: A. All the court yard exits and the exit at the end of C-hall exiting out onto Claggett have had exit alarms installed. These alarms were also glued in the on position, to eliminate the ability for staff or residents to disable the alarms. B. All alarms for the exit doors will be glued in the on position, disabling the ability for staff or residents to turn them off. So that they will always be working and alert all staff when someone exits or enters the building. 2. Education provided to all staff and residents on the necessity and need of working door alarms for all exits. The need for the staff to be alerted when anyone enters or leaves the building for safety purposes. Staff and residents were also educated to notify management if the alarms do not go off when they are exiting the building. Maintenance Manager or designee will complete monitoring,testingand replacing batteries in all exit alarms will entered as a Preventative Maintenanve task into TELS to be checked on a monthly basis. 3. The administrator or designee will print out the report from TELS showing that the testing has been completed and include the report in the monthly CQI meeting. This will printed and monitored monthly for 3 months, and then quarterly for 1 quarter, and then if task is completed per TELS, then it will be reviewed annually there after.

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:

OAR411-004-0020(2)(b) Physical Setting: Individual Accessible (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (b) The setting is physically accessible to an individual. This Rule is not met as evidenced by: Based on interview and observation, it was determined the facility failed to ensure the outside courtyard area was physically accessible to residents without staff assistance. Findings include but are not limited to: During an interview on 11/21/24 at 10:18 am, Staff 1 (Administrator) stated the center courtyard door was “heavy, hard to manage, and swung back hard”, and the residents were unable to access the courtyard without staff assistance. Observation of the center courtyard door on 11/21/24 at 11:32 am revealed the door was heavy and hard to push open. The door swung back quickly upon closing and approximately one foot beyond the door threshold into the building hallway. The need to ensure the facility provides physically accessible outdoor space which residents can access without staff assistance was discussed with Staff 1, Staff 2 (Administrator in Training), and Staff 5 (RN) on 11/21/24. They acknowledged the findings.

1. We have hired a contractor that has set the date for replacement on 01/18/2025. The contractor has committed to replacing the door going out into the courtyard across from the dining room, with french doors, that will allow the residents to be able to access the courtyard without asking for assistance. 2. Once replaced the doors will be maintained in good working order. 3. Once the work is completed, the door will be added into in the monthly walking rounds (added to TELS scheduled tasks) with maintenance director and administrator or designee. This will ensure that the door is in good working order at that time. If anything needs repaired it will be put on a work order and repaired. 4. Maintenance director or designee will be responsible for making sure the contractor completes the job to the specs of the accepted bid and meets the OAR requirements cited and then check monthly as scheduled for Preventative Maintenance and repaired as needed.

OAR411-004-0020(2)(b) Physical Setting: Individual Accessible (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (b) The setting is physically accessible to an individual. This Rule is not met as evidenced by: