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 ensure the preparation, completeness, and accuracy of documentation or records for 3 of 4 sampled residents (#s 1, 2, and 4) whose records were reviewed. Findings include, but are not limited to: During the survey resident records for residents 1, 2, and 4 were reviewed and were found to be missing, incomplete, or inaccurate in multiple areas, including signed physicians' orders, hospital discharge paperwork, hospice admission, outside provider notes, service plans, and RN assessments. The need to ensure resident records were complete and accurate was discussed with Staff 1 (ED) and Staff 2 (Regional Director) on 03/27/25. They acknowledged the findings. Refer to C260, C270, and C280.

1.The resident charts for sample resident #1 and #2 (resident sample #4 has passed away), have been reviewed and updated to reflect accurate and complete documents including but not limited to assurance of signed physicians' orders, hospital discharge paperwork, hospice admissions, outside provider notes, service plans, and RN assessments. We are reviewing, and updating all resident records to ensure resident records are accurate and complete. 2.All records are being reviewed to ensure they are complete using the triple check process and during the daily clinicals. A documented training will be provided to staff on the Triple check process and the importance of ensuring that all documents are accurate and complete. 3. Corrections are being evaluated daily during the daily clinical meetings. 4. The Administrator/Designee RCC, and LN will be responsible for corrections and monitoring to ensure compliance.

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 411-054-0036 (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 instructions to staff, and/or were implemented for 3 of 4 sampled residents (#s 1, 2 and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 07/2023 with diagnoses including lymphedema, dysphagia (difficulty swallowing), gastroesophageal reflux disease, and obesity. The resident’s service plan dated 02/18/25 and intermediate service plans dated 12/24/24 to 03/24/25 were reviewed, observations of the resident were made, and interviews with staff and the resident were conducted. The resident’s service plan was not reflective, did not provide clear direction to staff, and/or was not implemented in the following areas: * Instructions to speak in an elevated clear voice on the resident’s left side due to hearing loss; * Lymphedema and instructions for monitoring; * Dietary needs, including mechanical soft texture, medications crushed, reflux and aspiration precautions; * Sleep patterns and ensure head of bed remains at 30 degrees or more; * Grooming assistance; * Bathing assistance including role of hospice; * Incontinent care assistance and use of barrier cream; * Safety, including ability to use call light, frequency of safety checks, evacuation instructions; * Instructions to staff regarding side rails; * Life enrichment and activity preferences; and * Preference for door to remain open. The need to ensure service plans were reflective, provided clear direction to staff, and were implemented was discussed with Staff 1 (ED) and Staff 2 (Regional Director) on 03/27/25. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 09/2021 with diagnoses including morbid obesity, insulin dependent diabetes mellitus type 2, and chronic obstructive pulmonary disease (COPD). Observations were made of the resident's care on 03/25/25 and 03/26/25, interviews with the resident and facility staff were conducted, and the service plan dated 02/17/25 was reviewed. Resident 2's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Instructions to staff on providing care to the resident with significant vision impairment; * Instructions on signs and symptoms of hypo- and hyperglycemia to report; * Instructions for proper maintenance of blood sugar monitor on left upper extremity and how to monitor for malfunctions; * Instructions to staff on blood glucose monitoring protocol when resident slept late and skipped meals; * Oxygen equipment precautions, instructions for proper maintenance, and how to monitor for safety; * Instructions for aspiration precautions and interventions while choking; * How side rails were to be used and monitored for safety; * History of dehydration; * Non-pharmaceutical interventions for pain, including how a person expresses pain or discomfort; * How a person expresses memory loss; * Instructions on to whom to report skin impairments; * Personality, including how the person copes with change or challenging situations; * Number of staff needed to assist with emergency evacuations; * Instructions on peri and skin care; * Skin and wound condition monitoring; * Use of barrier cream with toileting changes; and * Electric wheelchair equipment precautions and instructions for proper maintenance. The need to ensure service plans reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (ED) and Staff 2 (Regional Director) on 03/27/25 at 11:16 am. They acknowledged the findings. 3. Resident 1 moved into the facility in 06/2023 with diagnoses including left partial hip replacement due to left hip fracture and chronic atrial fibrillation. The resident’s service plan dated 03/06/25 and intermediate service plans dated 01/29/25 to 03/22/25 were reviewed, observations of the resident were made, and interviews with staff and the resident were conducted. The resident’s service plan was not reflective or did not provide clear direction to staff in the following areas: * Left posterior hip precautions; * Outside providers, including home health admission; * Safety, including ability to use call light, frequency of safety checks, evacuation instructions; * Fall interventions; and * Use of shower chair for bathing assistance. The need to ensure service plans were reflective, provided clear direction to staff, and were implemented was discussed with Staff 1 (ED) and Staff 2 (Regional Director) on 03/27/25. They acknowledged the findings.

1.The resident charts for sample resident #1 and #2 (resident sample #4 has passed away), have been updated to reflect clear instructions on their service plans including, instructions to staff on providing care with significant vision impairment, signs & symptoms of hypo-and hyerglycemia to report, maintenance of blood sugar monitor and how to monitor malfunctions, and blood glucose monitoring protocol when a resident sleeps late, and/or skips meals. All other identified areas needing corrections have been made. 2. We are reviewing and updating all service plans by gathering resident specific information to build the service plan with the service planning team to include the resident, family, and staff. 3.The service plan will be reviewed and updated initially, 30 days, quarterly, and with any change of condition. 4.The Administrator/Designee will be responsible for corrections and monitoring to ensure compliance.

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

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had a significant change of condition had their service plan updated as needed for 1 of 4 sampled residents (# 2), failed to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff, and document progress until the condition resolved for 2 of 4 sampled residents (#s 2 and 4) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 09/2021 with diagnoses including morbid obesity, insulin dependent diabetes mellitus type 2, and chronic obstructive pulmonary disease (COPD). Resident 2's progress notes, dated 12/22/24 through 03/23/25, service plan dated 02/17/25, additional intermediate service plans, after-visit summaries to the emergency department, and significant change of condition evaluation dated 03/12/25 were reviewed. a. The following significant change of condition lacked documentation the facility updated the service plan as needed: * 03/12/25: significant physical and cognitive decline. b. The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved: * 02/28/25: return to the facility after hospitalization related to aspiration pneumonia and influenza A from 02/20/25 through 02/28/25; * 02/28/25: discontinued orders for glipizide 5 mg (to control blood sugar), propranolol 40 mg (to control blood pressure), and oxygen therapy; * 02/28/25: diet texture was changed from regular to mechanical soft; * 02/28/25: order for medications to be crushed in puree; * 02/28/25: “[Resident] newly requires a mechanical soft diet texture and is also 1:1 feeding assistance”; * 03/02/25: “resident on alert for loss of appetite”; * 03/03/25: “…[resident] has had ‘little to no’ intake over the last 2 days”; * 03/03/25: ED visit related to altered mental status; and * 03/04/25: ED visit related to altered mental status and cough. The need to ensure the facility had a system in place to ensure residents who had a significant change of condition had their service plan updated, and to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff, and document progress until the condition resolved was discussed with Staff 1 (ED) and Staff 2 (Regional Director) on 03/27/25 at 11:16 am. They acknowledged the findings. 2. Resident 4 moved into the facility in 07/2023 with diagnoses including lymphedema and cellulitis. Progress notes and intermediate service plans dated 12/24/24 to 03/24/25 were reviewed, and the following was identified: a. A 03/04/25 progress note indicated the resident had “tenderness with palpation on the right foot”. There was no documented evidence actions or interventions were determined, documented, and communicated to staff on each shift. There was no documented evidence of written communication regarding the change of condition for caregivers on each shift. b. The following changes of condition lacked resident-specific instructions to staff: * 01/23/25 – new medication (cefpodoxime); * 01/24/25 – new medication (enalapril); * 01/27/25 – new medication (ciprofloxacin); * 02/08/25 – new medication (pantoprazole); * 02/19/25 – new medications (omeprazole and aspirin); and * 02/26/25 – new medication (furosemide). The need to ensure resident-specific actions or interventions were determined, documented, and communicated to staff on each shift, and written communication of changes of condition were provided to caregivers on each shift was discussed with Staff 1 (ED) and Staff 2 (Regional Director) on 03/27/25. They acknowledged the findings, and no further information was provided.

1.Resident # 4 has passed away. Resident #2’s Change of condition has returned to baseline cognitively and a change of condition has been completed by the RN and has been documented to reflect her current needs and are updated in the residents’ service plan and is resident specific demonstrating actions and interventions needed and have been communicated to staff such as to implement a mechanical soft diet with a 1:1 feeding assistance with crushed medications in puree. 2. The Daily clinical meeting will identify any short- or long-term changes in resident condition/needs and will be addressed immediately by the consulting nurse. 3. 24-hour book review will be evaluated daily during daily clinical and during scheduled weekly clinical review with the RN consultant. 4.The RCC, Executive Director, LN, and Operations Director will be responsible for ensuring compliance.

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

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure the RN performed a timely assessment, developed interventions based on the condition of the resident, or updated the service plan for 2 of 4 sampled residents (#s 1 and 2) who experienced a significant change of condition. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 09/2021 with diagnoses including morbid obesity, insulin dependent diabetes mellitus type 2, and chronic obstructive pulmonary disease (COPD). Resident 2's progress notes, dated 12/22/24 through 03/23/25, service plan dated 02/17/25, additional intermediate service plans, after-visit summaries to the emergency department, and significant change of condition evaluation dated 03/12/25 were reviewed. Resident 2's clinical records and interviews with staff indicated the resident had experienced an overall decline in physical and cognitive status and an increase in ADL assistance. A decline in physical and cognitive condition following hospitalization from 02/20/25 through 02/28/25 represented a significant change of condition for which a timely RN assessment was required. An RN assessment was completed on 03/12/25, ten days later. Additionally, there was no documented evidence interventions were made as a result of this assessment and service plan was updated. The need to ensure the facility RN assessed all significant changes of condition timely and made interventions as a result of the assessment was discussed with Staff 1 (ED) and Staff 2 (Regional Director) on 03/27/25 at 11:16 am. They acknowledged the findings. 2. Resident 1 moved into the facility in 06/2023 with diagnoses including left partial hip replacement due to left hip fracture and chronic atrial fibrillation. The resident's 12/27/24 to 03/24/25 progress notes were reviewed. The following was identified: Resident 1 was admitted to hospice on 12/28/24, which constituted a significant change of condition that required a timely RN assessment that documented findings, resident status, and interventions made as a result of the assessment. An RN assessment was completed on 02/05/25, or 39 days after the significant change of condition occurred. On 03/25/25 at 2:20 pm, Witness 1 (LPN Consultant) acknowledged that the RN assessment was not completed timely. The need to ensure an RN assessment was completed timely for a significant change of condition was discussed with Staff 1 (ED) and Staff 2 (Regional Director) on 03/27/25. They acknowledged the findings.

1.The service plan for sample resident # 2 has been updated to reflect clear instructions to provide care due to the resident's short term physical and cognitive decline. The residents’ long-term change of diet texture, crushed medications given in puree and feeding assistance needs have been updated in the service plan with clear resident specific directives for the staff. Sample resident #4 has passed. 2. We are reviewing all residents charts to identify any changes of condition and/or monitoring needing updating with clear instructions to meet the care needs of the resident. The RN will provide a nursing assessment if, and when a Change of Condition is identified. LPN is enrolled and will be completing the NurseLearn class on Changes of Conditions. We have an RN consultant supporting the community until a community RN is recruited. When we are able to recruit an RN, we will have them complete the NurseLearn Change of condition class. Staff will be provided with documented training on changes of condition and reporting those changes. 3. A daily clinical meeting to evaluate 24 hours of any resident changes and weekly reviews with the RN Consultant. 4. The Administrator/Designee and LN will be responsible for corrections and monitoring 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:

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 2 of 4 sampled residents (#s 2 and 4) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 07/2023 with diagnoses including lymphedema. The resident’s 03/01/25 to 03/24/25 MAR and physician orders were reviewed, and the following was identified: The resident had an order for wound care treatment to be provided two times per day, at 10:30 am and 7:00 pm. The MAR was not filled out for the 10:30 am treatment on 03/02/25, 03/03/25, 03/04/25, and 03/09/25. In an interview at 10:26 am on 03/26/25, Staff 6 (CG) confirmed the treatments had not been provided. The need to ensure treatment orders were carried out as prescribed was discussed with Staff 1 (ED) and Staff 2 (Regional Director) on 03/27/25. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 09/2021 with diagnoses including morbid obesity, type 2 insulin dependent diabetes mellitus, and chronic obstructive pulmonary disease (COPD). Resident 2's current physician orders, MARs from 03/01/25 through 03/24/25 were reviewed, and interviews with facility staff and the resident were conducted. The resident was hospitalized from 02/20/25 through 02/28/25 for influenza and aspiration pneumonia. The hospital emergency department (ED) after-visit summary, dated 02/28/25, was received by the survey team on 03/26/25 and contained the following physician orders: * Stop taking propranolol 40 mg (for blood pressure) and glipizide 5 mg (to control blood glucose). However, according to the MAR, both medications were administered on 03/01/25 and 03/02/25; * Implement diet recommendation of mechanical soft diet texture. Based on observation of breakfast and lunch meals on 03/25/25 and 03/26/25, Resident 2 was given a regular texture diet with food cut into pieces by staff providing 1:1 feeding. After review of the discharge orders by this surveyor on 03/26/25, Witness 1 (LPN) was notified of the diet texture order and stated the prescribed texture was scheduled to be implemented starting 03/27/25. There was no negative outcome to Resident 2. No meals were observed on 03/27/25 because Resident 2 was sent to the ED for evaluation of suspected urinary tract infection; and * Directed staff to administer medications by crushing in puree. During the interviews with Staff 16 (MT) on 03/24/25 at 3:10 pm and with Staff 4 (MT) on 03/26/25 at 3:05 pm, both confirmed the resident was taking medications whole, one pill at a time with water. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (ED) and Staff 2 (Regional Director) on 03/27/25 at 1:16 pm. They acknowledged the findings.

1. Sample resident # 4 passed. Sample resident # 2’s Physicians orders have been compared to the MAR for accuracy and both the treatment aid and Med Techs have had refresh training on documentation and administration of medications including a refresh textures of medication administration in the right method and documentation. All staff have been reeducated on diet textures and 1:1 feeding assistance for resident 2 and any other altered textured delivery diets. 2. During daily clinical meetings treatments will be reviewed . The medication treatment aid will meet at the Med Tech meeting every other Wednesday for continuous training. The kitchen director will be doing random observations of food preperations to include textures being served are complient to diet orders. 3. A daily clinical meeting to review 24 hours of any resident changes and so we have clear instructions in place to be able to meet the needs of the residentand monitor compliance of orders. 4.The RCC, Program director,LN, and the ED will ensure corrections are made, and monitored daily. The LN will ensure accuracy and completion of Medication administration and documentation with oversite of the Executive Director.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by:

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 according to the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety records dated 10/05/24 through 03/06/25 were reviewed on 03/25/25 at 10:38 am with Staff 15 (Maintenance Supervisor) and Staff 7 (Lead Enrichment). The following was identified: Fire drill documentation did not include problems encountered, comments relating to residents who resisted or failed to participate in the drills. During an interview on 03/25/25 at 10:45 am, Staff 15 stated he met with the Fire Marshal regarding how to best assist residents who refused to participate in fire drills. Staff 15 stated the plan was to close any fire doors as well as resident room doors who chose not to participate in the fire drill and place a blanket underneath the gap at the bottom of their door. Staff 15 stated the Fire Marshal indicated the sprinkler system should be sufficient until the fire department arrives to assist with rescue. However, there was no documented evidence of approval for this plan by the Fire Marshal. The need to follow all OFC requirements for fire drills and documentation was discussed with Staff 1 (ED) and Staff 2 (Regional Director) on 03/27/25 at 12:45 pm. They acknowledged the findings. No additional information was provided.

1. Fire drills are scheduled to include resident participation and to address individually residents refusing to participate in the evacuation process. The Fire Marshalls response to appropriate evacuation plans has been received and we are awaiting a final written response. 2.A monthly schedule with alternating months from the fire drills will be then followed to ensure compliance with Fire drills and Fire & Life Safety. 3. The Fire Drill/Fire & Life Safety binder will be evaluated monthly. 4.The Administrator/Designee will be responsible to ensure corrections are completed and monitored.

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: