OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and preferences, provided clear direction regarding the delivery of services, and services were implemented for 1 of 2 sampled residents (#1) whose service plans were reviewed. Findings include, but are not limited to: Resident 1 was admitted to the facility in 11/2024 with diagnoses including macular degeneration and rheumatoid arthritis. Observations of the resident, interviews with staff and review of the most recent service plan, dated 01/03/25, showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff and/or was not being implemented in the following areas: * Outside providers, including HH PT and private caregiver services being provided; * Personal preferences and routines for bathing, bowel and bladder management, and personal hygiene including washing face, oral care, and hair; * Behavior interventions; * Preferences for room temperature and items within reach; and * Safety instructions for bed halo safety ring. The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and were implemented was discussed with Staff 1 (Health Services Administrator), Staff 2 (Senior ED), Staff 3 (ED) and Staff 4 (RN) on 02/26/25. They acknowledged the findings.

1. RN has corrected all items missing from the selected service plan (Resident 1). Temporary Service Plans (TSPs) were initiated for each missing item that was listed on the SOD. Items that have been initiated via TSP are as follows: - Outside providers, including HH/PT and private caregiver services being provided. - Personal preferences and routines for bathing, bowel and bladder management and personal hygiene including washing face, oral care and hair. - Behavior interventions. - Preferences for room temperature and items within reach. - Safety instructions for bed halo safety ring. 2. The Administrator or designee will review all current service plans to assure personalization and preferred routines are documented. Going forward, the Service Plan Feedback Form has been implemented to assure all information is documented and reflected in the service plan. The resident interview will continue to be utilized for feedback during new move-in, 30-day, quarterly review or significant change of condition evaluation processes. 3. Service plans will be evaluated for every resident at new move-in, 30-day, quarterly review, and significant change of condition. 4. The Registered Nurse, Resident Services Coordinator and the Health Services Administrator or designee will be responsible for assuring the corrections are completed and monitored moving forward.

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: