OAR 411-054-0025 (5) Facility Administration: Required Postings (5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following: (a) Facility license. (b) The name of the administrator or designee in charge. The designee in charge must be posted by shift or whenever the administrator is out of the facility. (c) The current facility staffing plan. (d) A copy of the most recent re-licensure survey, including all revisits and plans of correction as applicable. (e) The Ombudsman Notification Poster. (f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections. (g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted. (h) Other notices relevant to residents or visitors required by state or federal law. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure required postings were in a routinely accessible and conspicuous location to residents and visitors. Findings include, but are not limited to: The facility was toured on 12/17/24. The following were not posted as required: * The name of administrator or designee in charge posted by shift; * The LGBTQIA2S+ nondiscrimination notice; and * The Ombudsman notification poster was not posted in the separate memory care units 1 and 2. The need to ensure required postings were in a routinely accessible and conspicuous location to residents and visitors was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 4 (RCC) and Staff 6 (Director of Facilities) on 12/20/24. They acknowledged the findings.

Ombudsman poster for memory cares are ordered.12/22/24. All Posters posted 1/3/24 LBGTQIAS+ Are posted in Assisted living and both memory cares. Administrator Designee sign also posted. Signs will be checked monthly to ensure compliance by RCC/ADMIN

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 conduct an initial move-in evaluation for 1 of 1 sampled resident (# 4) and failed to ensure move-in evaluations addressed all required elements, for 2 of 2 sampled residents (#s 5 and 6) whose evaluations were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 08/2024 with diagnoses including dementia. Resident clinical records were reviewed, and no documented evidence of an initial move-in evaluation was found for Resident 4. During an interview on 12/18/24, Staff 1 (Administrator) reported an initial move-in evaluation had not been completed for Resident 4. On 12/19/24, the need to ensure the facility conducted an initial move-in evaluation prior to admission was discussed with Staff 1. She acknowledged the findings. 2. Resident 6 was admitted to the facility in 11/2024 with diagnoses including depression and essential hypertension. The move-in evaluation, completed on 11/27/24, failed to address the following required elements: *Mental health issues, including history of treatment and effective non-drug interventions; *Personality, including how the person copes with change or challenging situations; *Pain, including pharmaceutical and non-pharmaceutical interventions; and *Recent losses. The need to ensure all required elements were addressed in the move-in evaluation was discussed with Staff 1 (Administrator), Staff 2 (Executive Director) Staff 3 (LPN) and Staff 4 (RCC) at 11:00 am on 12/20/24. They acknowledged the findings. 3. Resident 5 moved into the facility in 11/2024 with diagnoses including hemiplegia and hemiparesis following cerebral infarction, and cognitive communication deficit. The resident's move-in evaluation was reviewed. The following required elements were not addressed: *Mental health issues, including history of treatment and effective non-drug interventions; * History of dehydration or unexpected weight loss or gain; and * Communication, including the ability to understand and be understood. The need to ensure the move-in evaluation addressed all required elements was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (LPN), and Staff 4 (RCC) on 12/20/24. They acknowledged the findings.

Resident #4 , # 5 and #6 will have an evaluation completed that addresses all required elements to ensure nothing was missed upon move in. Audit will be completed on all residents to ensure each resident has a move-in evaluation completed. Nurse Consultant will provide an in-service with the interdisciplinary team (IDT) on when to complete a resident evaluation. The HWD or designee will audit new move in (initial) evaluations for timeliness and all required elements. Audit details to be reported at Quarterly QA meeting.

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 6 of 6 sampled residents (#s 1, 2, 3, 4, 5 and 6) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 01/2019 and had diagnoses including Alzheimer's Disease and chronic pain. Observations of the resident, interviews with staff, review of interim service plans, progress notes from 10/10/24 through 12/16/24, and service plan, dated 11/20/24, showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas: * Ability to communicate effectively; * Symptoms of anxiety and agitation for staff to monitor; * Two-person assist for bed mobility, toileting, dressing, showers, and transfers; * Non-ambulatory; * Wheelchair for mobility; * Grooming and Hygiene; * Meal assistance; * Pressure reducing cushion in wheelchair; * Pain in legs, including non-drug interventions with direction for staff; and * Weight loss history and interventions. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), and Staff 3 (LPN) on 12/19/24. The staff acknowledged the findings. 2. Resident 3 was admitted to the facility in 08/2022 with diagnoses including chronic pain and Type 2 diabetes. The resident's 10/17/24 service plan and temporary service plans dated 09/17/24 to 12/17/24 were reviewed, interviews with staff and the resident were conducted, and observations were made. The resident's service plan was not reflective of needs and preferences, did not provide clear direction to staff, and/or was not implemented in the following areas: *Anxiety presentation; *Inappropriate behavior; *Hallucinations/delusions; *Resistance to care; *Level of assistance required for mobility/ambulation, transferring, bathing, grooming, dressing and toileting; *Ability to use call pendant; *Emergency evacuation; *Pain including nonpharmacological interventions; and *History of weight loss. The need to ensure service plans were reflective, provided clear direction to staff, and were implemented was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (LPN) and Staff 4 (RCC) at 11:00 am on 12/20/24. They acknowledged the findings. 3. Resident 6 was admitted to the facility in 11/2024 with diagnoses including depression and essential hypertension. The resident's 11/27/24 service plan and temporary service plans dated 11/27/24 to 12/17/24 were reviewed, interviews with staff and the resident were conducted, and observations were made. The resident's service plan was not reflective of needs and preferences, did not provide clear direction to staff, and/or was not implemented in the following areas: *Vision loss and assistive devices; *Anxiety including symptom presentation and nonpharmacological interventions; and *Assistance required with dressing and emergency evacuation. The need to ensure service plans were reflective, provided clear direction to staff, and were implemented was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (LPN) and Staff 4 (RCC) at 11:00 am on 12/20/24. They acknowledged the findings. 4. Resident 5 moved into the facility in 11/2024 with diagnoses including hemiplegia and hemiparesis following cerebral infarction, and cognitive communication deficit. The resident’s service plan dated 11/14/24 was reviewed, observations were made, and interviews were conducted. The resident's service plan was not reflective of the resident’s needs and preferences and did not provide clear direction to staff in the following areas: * Level of transfer assistance; * Level of ambulation/locomotion assistance; * Compression socks; and * Resident preference for leaving apartment door open. The need to ensure service plans were reflective of residents' current needs and provided clear direction to staff for the provision of care was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (LPN), and Staff 4 (RCC) on 12/20/24. They acknowledged the findings. 5. Resident 2 was admitted to the facility in 07/2022, with diagnoses including dementia, depression, and hypertension. Review of Resident 2's most recent service plan, dated 11/18/24, interviews with staff, and observations of the resident revealed the service plan was not reflective of current status and care needs, or did not provide clear direction for staff in the following areas: * Dietary strategies and weight loss concerns; * Person-centered activity plan; and * Risk for skin breakdown. On 12/19/24 at 2:15 pm, the need to ensure service plans were reflective of current status and care needs, and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (LPN), and Staff 4 (RCC). They acknowledged the findings. 6. Resident 4 was admitted to the facility in 08/2024 with diagnosis including dementia. Resident 4's service plan, progress notes, incidents reports, and staff interviews identified the service plan was not reflective of the resident's preferences, current status, or lacked direction to staff in the following areas: * Dressing; * Ability to use a key; and * Resident unit door open or closed preference. On 12/19/24, the need to ensure service plans were reflective of resident needs and preferences was discussed with Staff 1 (Administrator). She acknowledged the findings.

Resident #1, #2, #3, #4, #5, #6 have been reviewed by the IDT to ensure their service plans reflect the resident’s current care needs and provide clear direction regarding delivery of services for all areas of care. Review of all resident service plans will be conducted to ensure the service plans are reflective of each resident’s care needs and provide clear direction to staff for the provision of care. Nurse Consultant or designee will provide education/in-service to the IDT on person centered service plans. HWD or Designee will review that the service plans are being updated quarterly and when there is a change in condition. Audit details to be reported at Quarterly QA meeting.

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 residents choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 2 of 4 sampled residents (#s 2 and 4) whose service plans were reviewed. Findings include, but are not limited to: Resident 2 and 4's most recent service plans lacked documentation a Service Planning Team reviewed and participated in the development of the service plans. On 12/19/24 at 2:15 pm, the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (LPN), and Staff 4 (RCC). They acknowledged the findings.

Resident #2 and #4 had another service plan meeting with resident/family invited and documentation was completed showing who participated in the service plan meeting. Beginning 1/13/25 the service planning team will complete the new form for each care conference held that includes who attended. The facility implemented a new service plan review form with each care conference effective 1/13/25. The HWD or Designee will audit for compliance 1x/week for 1 month and then 1x monthly thereafter. Audit details to be reported at Quarterly QA meeting

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 residents who experienced short-term changes of condition had resident-specific actions or interventions determined and documented, and residents' changes of condition were monitored consistent with evaluated needs with progress noted at least weekly to resolution for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5 and 6) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 08/2022 with diagnoses including chronic pain and Type 2 diabetes. The resident's service plan available to staff, dated 10/17/24, temporary service plans dated 09/17/24 to 12/17/24, 12/01/24 to 12/17/24 MARs and progress notes dated 09/17/24 to 12/17/24 were reviewed, observations were made, and interviews with staff and the resident were conducted. The following short-term changes of condition, documented in the progress notes, lacked actions or interventions communicated to staff on all shifts and/or were not monitored at least weekly to resolution: * 09/23/24 – Unwitnessed fall; * 09/24/24 – Right foot diabetic ulcer; * 09/25/24 – New medication; * 10/08/24 – New skin breakdown, coccyx; * 10/19/24 – Unwitnessed fall; * 11/01/24 – Unwitnessed fall; * 11/01/24 – New symptom, gout; * 11/07/24 – Difficulty swallowing pills; * 11/08/24 – Unwitnessed fall; * 11/13/24 – Severe shoulder pain; * 11/15/24 – Unwitnessed fall; and * 12/08/24 – Unwitnessed fall. The need to ensure changes of condition had actions or interventions determined, implemented, communicated to staff on all shifts, and were monitored at least weekly to resolution was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (LPN) and Staff 4 (RCC) at 11:00 am on 12/17/24. They acknowledged the findings. 2. Resident 6 was admitted to the facility in 11/2027 with diagnoses including depression and essential hypertension. The resident's service plan available to staff, dated 11/27/24, temporary service plans dated 11/27/24 to 12/17/24, 12/01/24 to 12/17/24 MARs and progress notes dated 11/27/24 to 12/17/24 were reviewed, observations were made, and interviews with staff and the resident were conducted. The following short-term changes of condition lacked actions or interventions communicated to staff on all shifts and/or were not monitored at least weekly to resolution: * 11/27/24 – New move-in; * 12/05/24 – Unwitnessed fall with injury; and * 12/09/24 – Return from hospital. The need to ensure changes of condition had actions or interventions developed, implemented, communicated to staff on all shifts, and were monitored at least weekly to resolution was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (LPN) and Staff 4 (RCC) at 11:00 am on 12/20/24. They acknowledged the findings. 3. Resident 1 was admitted to the facility in 01/2019 with diagnoses including Alzheimer’s disease and chronic pain. The resident's 11/20/24 service plan and progress notes, interim service plans dated 10/10/24 through 12/17/24 were reviewed. The following short-term changes of condition lacked monitoring of progress noted weekly through resolution: * 10/10/24 – Diarrhea; * 11/07/24 – Elevated temperature; and * 11/19/24 – Admission to hospice. The need to ensure changes of condition had progress monitored at least weekly through resolution was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), and Staff 3 (LPN) on 12/19/24. They acknowledged the findings. 4. Resident 2 was admitted to the facility in 07/2022 with diagnoses including dementia, depression, and hypertension. Review of Resident 2's progress notes, dated 09/17/24 through 12/17/24, indicated the resident experienced the following changes of condition: * 09/22/24: A progress note revealed the discovery of “scratches on [his/her] left shoulder near [his/her] collar bone” while being assisted in shower; and * 10/31/24: A progress note revealed “[Resident 2] has a small skin tear on [his/her] left wrist that seems to be from [his/her] watch”. There was no documented evidence these skin conditions were monitored, at least weekly, to resolution. On 12/19/24 at 2:15 pm, the need to ensure short term changes of condition were monitored with progress noted, at least weekly, to resolution was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (LPN), and Staff 4 (RCC). They acknowledged the findings. 5. Resident 5 moved into the facility in 11/2024 with diagnoses including hemiplegia and hemiparesis following cerebral infarction, and cognitive communication deficit. The resident’s service plan, interim service plans, progress notes, and off-site healthcare provider notes were reviewed, and interviews with staff were conducted. The following was identified: A fax to the resident’s physician dated 12/06/24 stated resident’s “right great toe is red, inflamed and warm. [S/he] appears to have cellulitis starting.” An urgent care visit summary dated 12/07/24 documented diagnoses of cellulitis of left lower limb and localized edema. During an interview at 1:15 pm on 12/18/24, Staff 3 (LPN) acknowledged there was no documentation the above change of condition was monitored. The need to ensure short-term changes of condition were monitored weekly with progress noted was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (LPN), and Staff 4 (RCC) on 12/20/24. They acknowledged the findings. 6. Resident 4 was admitted to the facility in 08/2024 with diagnosis including dementia. Resident 4's clinical record was reviewed for changes of condition and monitoring from 09/18/24 through 12/18/24 and revealed the following: * 11/10/24: Resident to resident altercation; * 11/22/24: Became unresponsive during a meal, slump in chair, hit their head on the table, and began drooling; * 11/26/24: Found on the floor and was sent to the hospital; * 11/28/24: Found on the floor in front of their couch; * 11/29/24: Open skin area to the second digit of his/her right foot; and * 12/12/24: Found on the floor of the bathroom. There was no documented evidence the facility monitored the short-term changes of condition weekly through resolution. On 12/19/24, the need to monitor resident changes of condition weekly to resolution was reviewed with Staff 1 (Administrator). She acknowledged the findings.

Resident #1, #2, #3, #4, #5, #6, short term condition changes will be re-capped by the LN to ensure issues have been resolved and no further action/interventions are needed. LN to review short-term changes in condition for all other residents over the past 30-days (month of December) to ensure any issues/concerns have been resolved and/or need further action/interventions. THOUGHTS ON THIS ONE? Change in resident’s condition will be monitored and identified through the 24-hour chart review and follow-up process. The facility implemented a new 24-hour/alert charting policy and procedure/system. Changes in conditions will also be discussed at morning clinical meetings. Licensed nursing staff will be in-serviced on assessing and documenting changes in condition on a weekly basis until resolution. Med-techs and caregivers will be in-serviced on the new 24-hour and alert charting policy and procedure and reporting process for changes in resident conditions. Monthly audits will be completed by the Health and Wellness Director (HWD) or Designee to ensure that monitoring of changes in condition has been assessed timely and documented on weekly until resolution. Audit details to be reported at Quarterly QA meeting. HWD to ensure compliance

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed which documented findings, resident status, and interventions made as a result of the assessment for 1 of 2 sampled resident (# 1) who experienced a significant change of condition. Findings include, but are not limited to: Resident 1 was admitted to the facility in 01/2019 with diagnoses including Alzheimer’s disease and chronic pain. During the acuity interview on 12/17/24, staff reported the resident needed two-person assist with transfers and was “heavy care” for ADLs. Observations of Resident 1 during survey revealed s/he remained in bed for most of the time, getting up only for two meals. Two staff provided assistance with bed mobility, incontinence cares, dressing and transfer to the wheelchair. Total one person assist was provided for grooming and hygiene tasks. Interviews with staff and review of the resident's 11/20/24 service plan, temporary service plans, and 10/10/24 through 12/17/24 progress notes, were completed. The service plan, with an activation date of 07/09/24, last updated on 11/20/24, indicated the resident required minimum assist with transfers, was ambulatory with a walker up to 150 feet and set up, supervision and cueing for grooming and hygiene as needed. Staff 13 (CG) and Staff 19 (CG) reported that Resident 1 was not able to walk any longer, needed total one to two person assist in all ADL cares, and at times feeding assist was provided. Staff reported that in 08/2024 the resident was able to ambulate with a walker with one person assist. During an interview with Staff 5 (RN) on 12/18/24, she reported an assessment had been completed for Resident 1. She provided documentation of an RN change of condition note dated 11/21/24 indicating hospice services had been started on 11/19/24, without any documentation related to the resident’s significant decline in ADLs and mobility. The need to ensure an RN assessment was completed for significant changes of condition which included resident status and interventions made as a result of the assessment was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), and Staff 3 (LPN) on 12/19/24. No further documentation was provided.

The RN completed a significant change in condition assessment for resident #1 and updated interventions to reflect her current ADL’s and medical condition. The HWD or designee will audit all resident charts who are on hospice to ensure there is an RN change in condition assessment completed with interventions that have detailed instructions on resident’s current ADL and medical condition. Facility hired a new RN and will take "Role of the RN in CBC setting" on February 18th- 20th, 2025. RN/LPN will enroll in the Nurse Learn program for Licensed Nurses and take the modules for Changes in Resident Condition. Significant changes in resident condition will be monitored and identified through the 24-hour chart review and follow-up process. The facility implemented a new 24-hour/alert charting policy and procedure/system. Changes in conditions will also be discussed at morning clinical meetings for appropriate follow-up by RN. Monthly audits will be completed by the HWD or designee to ensure that significant changes in condition have a RN assessment completed timely with detailed instructions/interventions for staff to follow. Results of audit to be reported to the QA meeting quarterly.

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 resident-specific parameters and instructions for PRN medications were included on the MAR and/or the MAR included all required components, including medication specific instructions, for 2 of 6 sampled residents (#s 2 and 3) whose MARs were reviewed. Findings include, but are not limited to: 1.Resident 3 was admitted to the facility in 08/2022 with diagnoses including chronic pain and Type 2 diabetes. The resident's 12/01/24 to 12/17/24 MAR was reviewed and revealed the following: a. PRN medications for pain lacked resident-specific parameters for administration: *Hydrocodone-acetaminophen 5-325 mg; and *Acetaminophen 325 mg. b. There was no documented evidence of resident-specific instructions for administration of PRN naloxone 4 mg/0.1ml (for opioid overdose). c. There was no documentation of where the Buprenorphine transdermal patch (for pain) was applied. d. Medication administration instructions for levothyroxine 150 mcg (for hypothyroidism) including that the medication should be taken 30 minutes before food, coffee, or other medications and on an empty stomach, were not included on the MAR. The need to ensure medications contained resident-specific parameters and instructions for administration was discussed with Staff 1 (Administrator), Staff 2 (Executive Director) Staff 3 (LPN) and Staff 4 (RCC) at 11:00 am on 12/20/24. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 07/2022, with diagnoses including dementia, depression, and hypertension. Review of Resident 2’s MAR, dated 12/01/24 through 12/17/24, identified the following: The MAR lacked resident-specific parameters for use of the following PRN pain medications, and PRN bowel medications: * Four PRN medications for constipation were listed on the MAR: bisacodyl 10 mg supp, Senna 8.6 mg tab, Milk of Magnesia 400 mg/5ml, Glycerin 2 gm supp. There were no instructions for the sequential order of administration of these medications; and * Three PRN medications for pain were listed on the MAR: acetaminophen 325 mg tab (for pain or fever), acetaminophen 650 mg supp (for pain or fever) and morphine sulfate 100 mg/5 ml sol (for pain or shortness of breath). There were no instructions for the sequential order of administration of these medications. The need to ensure MARs were accurate, and included clear parameters and direction to staff for medication administration was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (LPN), and Staff 4 (RCC). They acknowledged the findings.

Resident #3 and #2 EMARs were reviewed and updated to include resident specific instructions/parameters for prn medications. Licensed nurse will review all resident MARs for appropriate instructions/parameters for all PRN medications. Licensed Nurse to include resident specific instructions/parameters for prn medications during process of confirming orders. Pharmacy Consultant or designee will audit for resident specific instructions/parameters during their quarterly audit. HWD will follow-up to ensure recommendations have been completed. Nurse Consultant will do random audits during routine visits to ensure compliance.

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 interview, and record review, it was determined the facility failed 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 and had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications for 1 of 1 sampled resident (# 7) who was reviewed for self-administration. Findings include, but are not limited to: Resident 7 was admitted to the facility in 12/2023 with diagnoses including arthritis and diabetes. During the acuity interview on 07/22/24, Resident 7 was identified as self-administering his/her medications. Review of Resident 7's medical records revealed there was no documented quarterly evaluation of Resident 7's ability to safely self-administer medications after 07/10/24, and no physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications. In an interview on 12/18/24, Staff 1 (Administrator) acknowledged no physician or other legally recognized practitioner's written order was available, and the most recent quarterly evaluation was not completed timely. 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 and had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications was reviewed with Staff 1, Staff 2 (Executive Director), and Staff 3 (LPN) on 12/19/24. They acknowledged the findings. No further information was provided.

Licensed Nurse to complete a self-med assessment for resident #7 and obtain a physician order if appropriate. LN will assess a resident upon move-in and if assessed to be able to safely administer their medications will obtain a physician’s order and will complete a self-med assessment quarterly thereafter or when there is a change in condition or ability to self-administer own medications. HWD or designee will review all residents who are administering their own medications to ensure there is a self-med assessment completed by a LN at least quarterly and/or with a change in condition and that there is a physician’s order in place to self-administer. HWD or designee to monitor for compliance monthly x2 months and then quarterly thereafter.

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed by an RN, PT or OT, less restrictive alternatives prior to use were documented, instruction was provided to caregivers on the correct use of and precautions for the device, and use of the device was documented in the resident's service plan for 2 of 2 sampled resident (#s 1 and 3) who had side rails on his/her bed. Findings include, but are not limited to: 1.During an interview at 9:54 am on 12/19/24, Resident 3 stated s/he had bilateral side rails on his/her bed. Interviews with care staff confirmed the resident did currently have side rails on his/her bed. There was no documented evidence the following required elements were completed: * Thorough assessment by an RN, PT or OT; * Documentation of less restrictive alternatives evaluated prior to use of the device; * Instruction provided to staff on the correct use and precautions related to the device; and * Documentation of side rails in the resident's service plan. The need to ensure the use of a supportive device with potentially restraining qualities was assessed by an RN, PT or OT, included documentation of all required elements and was included in the resident's service plan was discussed with Staff 1 (Administrator), Staff 2 (Executive Director) Staff 3 (LPN) and Staff 4 (RCC) at 11:00 am on 12/20/24. They acknowledged the findings, and no additional documentation was provided. 2. Resident 1 was identified during acuity interview as having side rails on his/her bed and was observed on 12/17/24 to have half side rails in the up position on both sides of the bed. Review of the resident's clinical record revealed the following: * No documented evidence of an assessment completed by an RN, Physical Therapist or Occupational therapist for the use of the side rail or seatbelt; and * No documented evidence that other less restrictive alternatives had been attempted prior to use. The need to complete an assessment and the required components for the use of devices with restraining qualities was discussed on 12/17/24 with Staff 1 (Administrator) and 12/19/24 with Staff 1, Staff 2 (Executive Director) and Staff 3 (LPN). They acknowledged the findings. The side rails were removed from the bed on 12/18/24.

Resident #1 siderails were removed from bed on 12/18/24. Resident #3 device with restraining quality had an assessment completed on and service plan was updated to reflect current device being used. RN to assess each resident who has a device with restraining qualities and document required elements on service plan. Residents with current devices will be re-assessed on a quarterly basis and/or with a change in condition. The HWD or designee to monitor for compliance monthly x2 months and then quarterly thereafter.

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 ensure their Acuity-Based Staffing Tool (ABST) accurately captured care time and care elements that staff were providing to residents. Findings include, but are not limited to: A review of the facility’s ABST revealed the care times and care elements documented for cares provided by staff were not accurate for Residents 1, 4, and 6. On 12/19/24 the need to ensure the ABST accurately captured care time and care elements was discussed with Staff 1 (Administrator). She acknowledged the findings.

Resident #1, #4, #6 were updated on the ABST to reflect current care time and care elements that staff provide to these residents. The Administrator will review all other residents on the ABST to ensure the Acuity Based Staffing Tool accurately captures care time and elements. Administrator will be inserviced On completing ABST This will be done upon move in, quarterly, with significant change of condition or as needed

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 the ABST (Acuity-Based Staffing Tool) was updated at least quarterly and/or with significant changes of condition to determine appropriate staffing levels to address activities of daily living and other tasks related to care. Findings include, but are not limited to: The facility had a census of 78 residents at the time of survey. Review of the facility’s ABST Tool showed 40 of 78 residents’ ABST information was not updated quarterly and/or with a signficant change of condition to reflect the residents’ current care needs and status. On 12/19/24, the need to ensure the ABST tool was updated no less than quarterly and with significant changes of condition to determine appropriate staffing levels to address activities of daily living and other tasks related to care was discussed with Staff 1 (Administrator). She acknowledged the findings.

The administrator will ensure that ABST is updated upon move in, Quarterly and with significant changes of condition Administrator or designee will review ABST for Accuracy for all residents Administrator will be inservied on completing the ABST

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 18, 21, 24, and 26) completed abdominal thrust training within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 12/20/24. There was no documented evidence Staff 18 (CG), Staff 21 (CG), Staff 24 (MT), and Staff 26 (MT) hired on 09/19/24, 10/18/24, 08/21/24, and 10/31/24 respectively, completed abdominal thrust training within 30 days of hire. On 12/20/24, the need for staff to complete all required training within the specified time frames was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), and Staff 4 (RCC). They acknowledged the findings.

Abdominal Thrust training, has been completed for 4 staff that were missing it by licensed Nurse All New employees will complete state required Training with in their first 30 days of hire. A licensed nurse will complete abdominal thrust training within 30 days of starting floor training. Annual training to be completed yearly, New hires will have Abdominal thrust training within 30 days of hire. Wellness director/ RCC/Admin to ensure this is completed.

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 every other month in accordance with the Oregon Fire Code. Findings include, but are not limited to: Review of fire drill and fire and life safety records for June 2024 through December 2024 identified the following deficiencies: * Fire drills were not being conducted and recorded every other month; * The facility was not relocating residents from the simulated fire area; therefore, there was no documentation of: - The escape route used; - Problems encountered, comments relating to residents who resisted or failed to participate in the drills; - Evacuation time-period needed; and - Number of occupants evacuated. On 12/19/24, multiple staff were interviewed. The staff were unable to state the designated point of safety as determined by the Fire Authority having jurisdiction. On 12/20/24, the need to ensure fire drills were conducted in accordance with the Oregon Fire Code was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), and Staff 6 (Director of Facilities). They acknowledged the findings.

Conduct all missing fire drills for the review by 2/18/25 ensuring proper documentation. Date time, simulated fire origin, escape routes, evacuation time, and staff/resident participation. Ensure residents are relocated to designated points of safety during drills. Provided refresher training to staff on fire evacuation procedures and designated points of safety. Fire drills and staff trainings have been set on an alternating schedule each month for the remainder of the year and ongoing. Fire drill documentation form has been updated to include all required elements. ED, Admin or designee to audit documentation monthly and correct as needed. ED, Admin, Maintenance Director or designee to monitor for compliance

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents were instructed in fire and life safety procedures within 24 hours of admission and re-educated at least annually. Findings include, but are not limited to: Fire and life safety records were reviewed on 12/19/24, and the following was identified: There was no documented evidence residents were educated in general fire and life safety procedures, evacuation methods, responsibilities, and designated meeting places inside or outside the building in the event of an actual fire within 24 hours of admission and re-educated at least annually. On 12/20/24, the need to ensure fire and life safety instruction was provided to each resident within 24 hours of admission and at least annually as required by the Oregon Fire Code was discussed with Staff 1 (Administrator). She acknowledged the findings.

1)By 2/18/25 will identify all residents missing fire life and safety covering general safety procedures, evacuation methods, responsibilities and meeting points. Document all training records with participation records. Provide initial training for new residents within 24hrs of admission.Update the admission process to include mandatory fire life and safety training. Annual fire life and safety was completed in April of 2024.Training scheduled for re-education for all residents during March of 2025. New move in's will be educated within 24hours of move in on fire life and safety plan. We will annually audit records to ensure re-education for all residents. Maintenance director, Admin or designee to ensure compliance.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (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 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. An ALF 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 must be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the environment was clean and maintained in good repair. Findings include, but are not limited to: The facility was toured on 12/17/24 and the following was observed: * The carpet in the hallway of the east side of the building on the 2nd floor had multiple dark stains of varying sizes throughout; * Several of the chairs in the dining room and common areas had gouges on the legs and were worn and stained in the memory care units 1 and 2; and * The toilets in the community bathrooms on the first and second floor near the elevator and the toilets in the community bathrooms in the memory care units 1 and 2 had missing or stained caulking around the base of the toilets. On 12/20/24, the areas in need of cleaning and repair were discussed with Staff 1 (Administrator), Staff 2 (Executive Director), and Staff 6 (Director of Facilities). They acknowledged the findings.

On 12/19/24 a contracted carpet cleaning company came during the noc hours to clean carpets noted in state findings. Caulking around toilets were completed in community restrooms on 1/09/25. Maintenance to train additional staff to perform carpet cleaning. Carpet cleaning will be completed bi weekly on Fridays and as needed. Common area and dining room chairs will be repaired and in good condition by 2/18/25. Monthly rounding with maintenance, ED , Admin or designee will be completed to ensure common area furniture and equipment is in good conditon.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 152, C 362, C 363, C 372, C 420, C 422, and C 613.

Refer to C152, C362, C363,C372, C420,C422 and C613

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 18, 21, 24, and 26) demonstrated competency in all job duties within 30 days of hire, and 3 of 4 long-term staff (#s 16, 17, and 21) completed the required number of hours of annual in-service training. Findings include, but are not limited to: Staff training records were reviewed on 12/19/24 and 12/20/24. a. There was no documented evidence Staff 18 (CG), Staff 21 (CG), Staff 24 (MT), and Staff 26 (MT) hired on 09/19/24, 10/18/24, 08/21/24, and 10/31/24 respectively, demonstrated competency in their job duties within 30 days of hire in the following areas: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Identification, documentation, and reporting changes of condition; * Conditions which require assessment, treatment, observation, and reporting; and * General food safety, serving, and sanitation. b. There was no documented evidence Staff 16 (CG), Staff 17 (CG), and Staff 25 (MT) hired on 05/10/22, 07/26/22, and 06/24/21, respectively completed the required minimum of 16 hours of annual in-service training, with 10 hours related to the provision of care in Community Based Care and six hours related to dementia care. On 12/20/24, the need to ensure all staff training was completed in the required time frames was discussed with Staff 1 (Administrator), Staff 2 (Executive Director) and Staff 4 (RCC). They acknowledged the findings.

The Four identified staff members completed their intial Competencies, The other three idenified staff members completed the annual training. Resident care coordinator will ensure documentation of demonstrated competency will be completed within 30 days of hire. RCC will ensure documentation of 16 hours annual inservice training with 10 hours of related to the provision of care in CBC and 6 hours related to dementia care is completed annually. Admin and RCC will be responsible for Compliance

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 252, C 260, C 262, C 270, C 280, C 310, C 325 and C 340.

Refer to C252, C260,C270, C280, C310, C325 AND C340

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 3 of 3 sampled MCC residents (#s 1, 2, and 4) whose activity plans were reviewed. Findings include, but are not limited to: Residents 1 ,2, and 4's records were reviewed during the survey. There was no documented evidence an activity evaluation had been completed and the service plans individualized, to reflect one or more of the following required components: * Residents' current preferences; * Abilities and skills; * Emotional/social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Identification of activities for behavioral interventions. There was no specific activity plan which detailed what, when, how and how often staff should offer and assist each resident with individualized activities. On 12/19/24 at 2:15 pm, the need to evaluate and develop individualized activity plans including all required components for each memory care resident was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (LPN), and Staff 4 (RCC). They acknowledged the findings.

Resident care coordinator will ensure activity plan is completed upon move in, and quarterly and if there is a change. Residents #1, #2 and# 4 have had activity plan completed. All Memory care residents charts will be audited to ensure there is a current activities plan in place. Activity plan will be kept in resident chart and a copy with their service plan available to staff. Rcc or designee to audit charts, and ensure completion of all memory care residents activities plan