OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure quarterly evaluations were completed timely for 2 of 4 sampled residents (#s 3 and 4) whose evaluations were reviewed. Findings include, but are not limited to: *Resident 3 was admitted to the facility in 07/2024, with diagnoses including chronic obstructive pulmonary disease and hypertension. The resident’s most recent quarterly evaluation was dated 08/12/24; and *Resident 4 was admitted to the facility in 08/2022, with diagnoses including congestive heart failure, chronic kidney disease, and dementia. The resident’s most recent quarterly evaluation was dated 08/07/24. On 05/07/25, the need to complete quarterly evaluations timely was discussed with Staff 1 (ED) and Staff 2 (Health and Wellness Director/LPN). They acknowledged the findings.

1. Evaluations for resident #3 and #4 were updated to reflect current status prior to surveyors exiting the community. 2. An audit will be completed of current resident records to assure presence of a current evaluation that is reflective of resident needs. Community nurses will receive additional education on rule requirements and forms completion. 3. Residents will be evaluated prior to move in, quarterly and upon change of condition. Executive Director or designee will conduct random audits on 4 resident records weekly for the next 60 days to ensure presence and accuracy of evaluation. 4. The Executive Director, Health & Wellness Director or designee will be responsible for overseeing that corrections are completed and monitored.

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, and provided clear direction regarding the delivery of services for 2 of 4 sampled residents (#s 3 and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 07/2024 and had diagnoses including chronic obstructive pulmonary disease, respiratory failure, and hypertension. The resident's current service plan, dated 04/11/25, was reviewed, observations were made, and interviews were conducted. The service plan was not reflective of the resident's needs and preferences, and did not provide clear instruction to staff in the following areas: * Side rails on the bed; * Episodes of increased confusion and hallucinations; * Ambulation; * Manual wheelchair mobility; * Hospice services provided; * Lower extremity edema; * Altered diet texture, to include instructions for refusals; and * Oxygen, to include instructions for oxygen tank changes, nasal cannula, concentrator filter change/cleaning, humified air for concentrator. The need to ensure service plans were reflective of resident needs and preferences and provided clear direction to staff was discussed with Staff 1 (ED), and Staff 2 (Health and Wellness Director/LPN) on 05/07/25. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 08/2022, with diagnoses including congestive heart failure, chronic kidney disease, and dementia. Resident 4’s most recent service plan, dated 04/11/25, was reviewed, observations were made, and interviews were conducted. The service plan was not reflective of the resident’s current care needs, or did not provide clear instruction to staff in the following areas: * Activities: past and current interests; * Dietary: nutrition and hydration; and * Physical Therapy services provided. On 05/07/25, the need to ensure service plans were reflective of current care needs, and provided clear instruction to staff was discussed with Staff 1 (ED) and Staff 2 (Health and Wellness Director/LPN). They acknowledged the findings.

1. The service plans for resident #3 and #4 have been reviewed and updated to reflect current status. 2. Remaining resident service plans will be reviewed to ensure they are reflective of residents' current care needs and preferences, and include clear direction regarding the delivery of services. As part of the routine service planning process, the Licensed Nurse or designee will conduct a record review and obtain feedback from care partners working directly with the resident prior to updating the service plan. 3. The Executive Director and/or designee will randomly audit 4 resident service plans weekly for 60 days to assure ongoing compliance. 4. The Executive Director, Health and Wellness Director or designee will be responsible for overseeing that corrections are completed and monitored.

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 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to: Resident 1, 2, 3 and 4's most recent service plans lacked documentation a Service Planning Team reviewed and participated in the development of the service plans. On 05/07/25, the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (ED) and Staff 2 (Health and Wellness Director/LPN). They acknowledged the findings.

1. The service plans for resident #1, #2, #3 and #4 will be reviewed with the resident and signatures obtained. 2. A service planning team will be utilized when developing a service plan that will include the resident, family as applicable or person of the residents choice, the Executive Director or designee, and at least one other staff person who was familiar with or provided services. A resident who declines a care conference will be provided with a paper copy of their service plan and notation documented in the record. 3. Executive Director and/or designee will conduct random audits of 4 resident service plans weekly for the next 60 days to ensure there is evidence of a service planning team. 4. The Executive Director will be responsible for overseeing that corrections are completed and monitored.

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 interview and record review, it was determined the facility failed to determine, document and communicate to staff what action or intervention was needed for a resident following a change of condition with weekly progress noted until the condition resolved, for 3 of 4 sampled residents (#s 2, 3, and 4) with documented changes of condition. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 10/2024 with diagnoses including peripheral vascular disease. The resident's service plan dated 02/24/25, MAR/TARs dated 04/01/25 through 05/05/25, progress notes and temporary service plans dated 02/09/25 to 05/05/25 were reviewed, observations were made, and interviews with staff and the resident were conducted. The resident experienced multiple short-term changes without documented monitoring of progress at least weekly until resolution and/or lacked resident-specific directions to staff in the following areas: * 02/24/25 – Foley catheter care; * 03/09/25 - New medication; * 04/10/25 – New medication; * 04/23/25 – New medication; and * 04/26/25 – New medication. During an interview with Staff 2 (Health & Wellness Director/LPN) on 05/07/25 at 10:50 am, she acknowledged the lack of monitoring of progress for changes of condition through resolution and the lack of actions or interventions determined and communicated to staff. The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED) and Staff 2 on 05/07/25. They acknowledged the findings. No further information was provided. 2. Resident 3 was admitted to the facility in 07/2024 with diagnoses including chronic obstructive pulmonary disease, hypertension and respiratory failure. The resident's service plan dated 04/11/25, MAR/TARs dated 04/01/25 through 05/05/25, progress notes and temporary service plans dated 02/09/25 to 05/05/25 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: * 2/22/25 Rash to right foot; * 3/1/15 Skin tear to back of right lower leg; * 4/9/25 Return from hospital with hospice admission, oxygen, progress note stating the resident had "no Able to safely swallow," and discontinuation of all non-comfort related medications; * 4/14/25 Diet order change to puree; * 4/16/25 Diet order change to minced moist mechanical soft; * 4/30/25 Edema to bilateral lower extremities; and * 5/2/25 Increased confusion in the evenings with some hallucinating. During an interview with Staff 3 (RN) on 5/6/25 at 12:10 pm, she acknowledged the lack of monitoring of progress for changes of condition through resolution, and the lack of actions or interventions determined and communicated to staff. The need to ensure all changes of condition had actions or interventions determined and communicated to staff on all shifts and were monitored at least weekly to resolution was discussed with Staff 1 (ED) and Staff 2 (Health and Wellness Director/LPN) at 12:20 pm on 05/07/25. They acknowledged the findings. 3. Resident 4 was admitted to the facility in 08/2022, with diagnoses including congestive heart failure, chronic kidney disease, and dementia. Review of Resident 3’s progress notes, dated 02/05/25 through 05/05/25, revealed the resident experienced the following changes of condition: * 03/07/25- Resident 4 took a fall, and was found seated on the floor in front of his/her recliner; * 03/31/25- The resident fell from a wheel chair while going down an outside ramp during a fire evacuation drill, sustaining multiple rib fractures; and * 04/17/25- The facility’s “Neighborhood Manual” (24 hour book) reported Resident 4 having a “rash forming on tailbone/bottom”. Temporary service plans (TSPs) were created following both of the falls. However, the TSPs lacked any new interventions, specific instructions to staff, or assessment of existing fall interventions for effectiveness. There was no documented evidence the skin rash was monitored or treated, from 04/17/25 through 05/01/25. On 05/07/25, the need to determine actions or interventions needed following changes of condition, communicate these to staff, with progress noted at least weekly until the conditions resolved, was discussed with Staff 1 (ED) and Staff 2 (Health and Wellness Director). They acknowledged the findings.

1. The record of resident #2, #3 and #4 will be reviewed in terms of the areas referenced in the deficiency report and records updated as applicable. 2. Current associates will be re-educated on recognizing and reporting changes in condition by June 6, 2025. Medication Technicians will be re-educated by June 6, 2025 on change of condition documentation to reflect at a minimum weekly documentation until the condition is resolved. Resident changes in condition will be discussed during routine staff stand up meetings and reviewed by the clinical team during routine clinical meeting to assure documentation is reflected in the resident records and updates are made to the service plan as applicable. 3. The Executive Director and/or designee will randomly audit 4 resident records weekly for 60 days to assure ongoing compliance. 4. The Executive Director, Health and Wellness Director or designee will be responsible for overseeing that corrections are completed and monitored.

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled resident (#s 2) whose MARs and Controlled Substance Drug Disposition logs were reviewed for accuracy. Findings include, but are not limited to: Resident 2 was admitted to the facility in 10/2024 with diagnoses including peripheral vascular disease. The current written prescriber orders and MARs dated 04/01/25 through 05/05/25 were reviewed during the survey. Resident 2 had a physician order for morphine sulfate 0.25ml, by mouth every two hours as needed for shortness of breath and/or pain. Review of the MARs and Controlled Substance Disposition Log revealed the following discrepancies: There were ten times a facility staff signed the Controlled Substance Disposition log indicating the morphine was removed from locked storage but did not document on the MAR that the medication was administered. The need to ensure the tracking of controlled substances was accurate was reviewed with Staff 1 (ED), Staff 2 (Health & Wellness Director/LPN) and Staff 3 (RN) on 05/07/25. They acknowledged the findings.

1. The medication administration record for resident #2 has been reconciled with the controlled substance log. 2. Current Medication Technicians will be re-educated on the process for documenting in the medication administration record and controlled substance logs by June 6th, 2025. The medication administration record for residents receiving controlled medications will be audited routinely twice monthly in conjunction with clinical meeting. 3. A random audit of 2 resident records will be completed weekly for the next 60 days to ensure medication and treatment documentation matches controlled substance logs. 4. Executive Director, Health and Wellness Director or designee will be responsible for overseeing that corrections are completed and monitored.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. 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 2 sampled Residents (#s 1 and 3) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 07/2024 and had diagnoses including chronic obstructive pulmonary disease, respiratory failure and hypertension. Resident 3's current physician's orders, MAR/TAR dated 04/01/25 through 05/05/25, and progress notes dated 02/09/25 through 05/05/25 were reviewed. The following was identified: a. The resident returned from a hospitalization on 04/09/25 with a physician’s order for PRN oxygen at 2 liters per minute (for shortness of breath or breathing difficulty). The order was not included on the MAR/TAR and therefore unavailable for staff to document administration as ordered, although Resident 3 was observed with oxygen on during survey, being administered at 1.5 liters per minute on 05/05/25, and at 2 liters per minute on 05/06/25. b. Additional orders from 04/09/25 included the following: * Oxygen concentrator filter cleaning instructions; * Oxygen humidifier canister instructions for providing humidified oxygen administration; and * Nasal cannula tubing to be changed twice monthly and as needed. Staff 2 (Health and Wellness Director/LPN) reported on 05/06/25 that the orders had not been transcribed to the MAR/TAR to be implemented. She stated she would be adding the orders to the MAR/TAR immediately. The need to ensure all medication and treatments were carried out as prescribed was reviewed with Staff 1 (ED) and Staff 3 at 12:20 pm on 05/07/25. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 03/2025 with diagnoses including pneumonia, glaucoma, hypertension, Myocardial Infarction and depression. The resident had signed orders dated 03/05/25 for the following medications and treatments which were not on the MAR/TAR: *Oxygen PRN: 1-4 LPM via nasal cannula to maintain saturation above 90%, every hour as needed; * Incentive Spirometer three times a day for increase lung capacity/activity tolerance; and * Speech Therapy Evaluate and Treat as indicated. On 05/07/25 at 11:05 am, Staff 3 (RN) stated on admission, pharmacy enters medication orders into the resident’s electronic health record and the facility nurse is responsible to enter the treatment orders. On 05/07/25 at 12:00 pm the need to ensure all orders were carried out as prescribed was discussed with Staff 1 (ED) and Staff 2 (Health and Wellness Director/LPN. They acknowledged the findings.

1. The Medication/Treatment Administration Record for resident #1 and #3 have been reviewed and updated to reflect current physician orders. 2. Remaining resident orders will be reviewed to assure accuracy. New or changed orders will be reviewed by the clinical team during routine clinical meeting to assure the medication administration record is accurate. Current Medication Technicians will be re-educated on the system for processing new orders and updating the resident record by June 6, 2025. 3. A random audit of 2 resident records will be completed weekly for the next 60 days to ensure medication and treatment orders are carried out as prescribed. 4. Executive Director, Health and Wellness Director or designee will be responsible for overseeing that corrections are completed and monitored.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused to consent to orders for 1 of 1 sampled resident (# 1) who had documented medication refusals. Findings include, but are not limited to: Resident 1 was admitted to the facility in 03/2025 with diagnoses including pneumonia, glaucoma, hypertension, Myocardial Infarction and depression. Resident 1's clinical records and MAR/TAR dated 03/06/25 through 05/05/25, were reviewed during the survey and revealed the resident had multiple medication refusals throughout 03/2025. The medications refused included: * Aspirin, refused 17 out of 17 times; and * Simvastatin, refused on 03/12/25. On 05/06/25 at 2:01 pm Staff 13 (MT) stated they notify provider via fax for each instance of medication refusal. On 05/07/25 at 10:05 am, Staff 2 (Health and Wellness Director/LPN) confirmed there was no documented evidence the facility notified Resident 1's physician of the refusals. On 05/07/25 at 12:00 pm the need to ensure physicians or other practitioners were notified each time a resident refused to consent to an order was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director/LPN). They acknowledged the findings.

1. The Aspirin order for resident #1 had been discontinued in March 2025. The primary care provider has been notified of the Simvastatin refusal from 3/12/2025. 2. The current medication administration records for remaining residents will be reviewed to assure physician notification per rule. Current Medication Technicians will be re-educated on the process for notifying the physician when a resident refuses consent to orders by June 6th 2025. Medication refusals will be reviewed by the clinical team during routine clinical meeting to assure physician notification per rule. 3. A random audit of 2 resident records will be completed weekly for the next 60 days to ensure medication and treatment orders are carried out as prescribed. 4. Executive Director, Health and Wellness Director or designee will be responsible for overseeing that corrections are completed and monitored.

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to document non-pharmacological interventions had been tried with ineffective results prior to administering a PRN psychotropic medication, for 2 of 2 sampled residents (#s 2 and 3) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 10/2024 with diagnoses including peripheral vascular disease. The resident was prescribed lorazepam (sedative to treat anxiety) 0.5 mg tablet - give 1 tablet every 4 hours as needed for agitation and/or anxiety and nausea. The MAR did not provide instructions to non-licensed staff regarding how the resident demonstrated signs and symptoms of agitation and/or anxiety behaviors for which staff could consider administering the medication; There were no resident-specific non-pharmacological interventions; and The MAR lacked common side effects of the medication and lacked instructions for when to contact a health professional regarding side effects. The need to have written, resident-specific parameters for PRN psychotropic medications, and to have non-drug interventions for staff to attempt and document ineffective results prior to administration of the psychotropic medications, was reviewed with Staff 1 (ED), and Staff 2 (Health and Wellness Director/LPN) on 05/07/25. They acknowledged the findings 2. Resident 3 was admitted to the facility in 07/2024 with diagnoses including chronic obstructive pulmonary disease, hypertension and respiratory failure. The resident was receiving hospice services. A review of the resident's 04/01/25 through 05/05/25 MAR, current physician orders, and 02/09/25 through 05/05/25 progress notes identified the following: Resident 3 had a signed physician order for the following PRN psychotropic medications: * Lorazepam 0.5 mg, one tablet by mouth every four hours as needed for increased anxiety and/or restlessness; and * Haloperidol 0.5 mg, every four hours as needed for hallucinations. The MAR did not provide instructions to non-licensed staff regarding how the resident demonstrated signs and symptoms of anxiety, restlessness or hallucination behaviors for which staff could consider administering the medications; There were no resident-specific non-pharmacological interventions; and The MAR lacked common side effects of the medication, and lacked instructions for when to contact a health professional regarding side effects. The need to have written, resident-specific parameters for PRN psychotropic medications, and to have non-drug interventions for staff to attempt and document ineffective results prior to administration of the psychotropic medications, was reviewed with Staff 1 (ED), and Staff 2 (Health and Wellness Director/LPN) on 05/07/25. They acknowledged the findings.

1. The medication administration record for resident #2 and #3 have been updated to include resident specific signs and symptoms of the behavior, non-pharmacological interventions, common side effects and when to report. 2. Remaining residents with orders for psychotropic medications will be reviewed for presence of information on the medication administration record as required by rule. Current Medication Technicians will be re-educated on the process for documenting non-pharmacological interventions attempted with ineffective results prior to administering an as needed psychotropic medication. 3. A random audit of 2 resident records will be completed weekly for the next 60 days to ensure medication and treatment orders are carried out as prescribed. 4. Executive Director, Health and Wellness Director or designee will be responsible for overseeing that corrections are completed and monitored.

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed by an RN, PT, or OT, other less restrictive alternatives evaluated prior to use of the device were documented, caregivers were instructed on the correct use of and precautions for the device, and use of the device was included in the resident's service plan for 1 of 1 sampled resident (#3) who had half side rails on their bed. Findings include, but are not limited to: Resident 3 was admitted to the facility in 07/2024 and had diagnoses which included chronic obstructive pulmonary disease, respiratory failure, and was receiving hospice services. During the acuity interview on 05/05/25, staff reported the resident had side rails on the bed. On 05/06/25 at 11:00 am, the resident's bed was observed to have half-length side rails in the up position on both sides of the bed. There was no documented evidence the device with restraining qualities had been assessed by an RN, PT, or OT, no documentation of other less restrictive alternatives evaluated prior to use of the devices, no documentation of instruction to caregivers on correct use of and precautions for the device, and no documentation of the use of the side rails in the resident's service plan. On 05/06/25 Staff 3 (RN) stated there was no RN, PT, or OT assessment of the side rails on the resident’s bed. The above information was discussed with Staff 1 (ED) and Staff 2 (Health and Wellness Director/LPN) on 05/07/25. Staff acknowledged the findings.

1. The supportive device for resident #3 was no longer needed and removed from the bed. 2. An audit of remaining resident apartments will be conducted to identify bedside supportive devices in use and confirm these have been evaluated by the Registered Nurse with associated documentation present in the resident record. Current staff will be re-educated on community policy for bedside assistive devices by June 6th, 2025. 3. The Executive Director and/or designee will randomly audit 4 resident apartments and records weekly for 60 days to assure ongoing compliance. 4. Executive Director, Health and Wellness Director and Registered Nurse will be responsible for overseeing that corrections are completed and monitored.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have a sufficient number of caregiving staff to meet the 24 hour scheduled and unscheduled needs of residents. Findings include, but are not limited to: The facility was home to 36 residents at the time of the re-licensure survey. During the acuity interview on 05/05/25, the facility identified several residents with high ADL care needs, and three residents who required two staff for transfers/mobility. Two of these residents resided on second floor, which presented significant challenges in the case of an emergency evacuation. The staffing record for a two week period, from 04/20/25 through 05/04/25, and the posted staffing plan were reviewed. The facility was consistently staffing two care staff on NOC shift. This was determined to be inadequate to meet resident needs, and to maintain sufficient readiness for a potential evacuation. During interviews with sampled and unsampled residents on 05/06/25 and 05/07/25, residents expressed the following concerns: * "They are shorthanded, especially on night shift"; * "Call lights can take over an hour to be answered on evenings and night shift"; * "They need more staff to take care of everyone here"; * "Sometimes I can wait for twenty to thirty minutes, after pushing my call light"; and * “I’m diabetic, and I really worry about getting help quickly, if I need it” On 05/07/25, the need to maintain sufficient staffing levels to meet the scheduled and unscheduled needs of the residents, and to maintain readiness for an emergency was discussed with Staff 1 (ED) and Staff 2 (Health and Wellness Director/LPN). They acknowledged the findings.

1. An additional night shift associate has been added to meet 24 hour scheduled and unscheduled needs of residents and posted staffing plan updated. 2. The community acuity based staffing tool has been reviewed by the Executive Director to assure accuracy. 3. The Executive Director will review the acuity based staffing tool (ABST) weekly to verify the posted staffing plan and staff schedule align with staffing patterns indicated by the ABST system. 4. Executive Director or designee will be responsible for overseeing that corrections are completed and monitored.

OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff (6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF. (a) Annual infectious disease training requires the following: (A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training. (B) Annual in-service training must be documented in the employee record. (b) Biennial LGBTQIA2S+ training requires the following: (A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff. (i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite. (ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. (vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state. (D) The proposal for training submitted by a facility, entity, or individual shall include: (i) The regulatory criteria described in paragraph (C) of this section as part of the proposal. (ii) The following elements must be included in the proposal: (I) A statement of the qualifications and training experience of the facility, individual or entity providing the training; (II) The proposed methodology for providing the training either online or in person. (III) An outline of the training. (IV) Copies of the materials to be used in the training. (iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision. (c) Annual Home and Community-Based Services (HCBS) training requires the following: (A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations. (B) Annual in-service training must be documented in the employee record. (C) These annual trainings will be required as of April 1, 2025. (7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF. (a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire. (b) Requirements for annual in-service dementia training: (A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care. (B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter. (C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above. (D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia. (E) The facility shall determine the competency of direct care staff in dementia care in the following ways: (i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19). (ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff. (iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency. (8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 3 long term direct care staff (#s16, 11, and 13) completed a minimum of 12 hours of in-service training annually including six hours on dementia care. Findings include, but are not limited to: Review of the facility's training records 05/06/25 revealed the following: 1. Staff 16 (CG) hired 02/15/21 did not have documented evidence of 12 hours of annual in-service training related to provision of care in CBC including six hours of dementia care, required annual infectious disease training, and HCBS training. 2. Staff 11 (MT) hired 03/28/11 did not have documented evidence of six hours of dementia care, and HCBS training. 3. Staff 13 (MT) hired 09/05/14 did not have documented evidence of six hours of dementia care, and HCBS training. The need to ensure all staff had a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a CBC, including dementia care topics, required annual infectious disease training, HCBS and LGBTQIA2S+ training, was discussed with Staff 1 (ED) and Staff 2 (Health & Wellness Director/LPN), and Staff 8 (Business Office Coordinator) on 05/07/25. They acknowledged the findings.

1. Staff #11, #13 and #16 are scheduled for required training as outlined in the statement of deficiencies. An annual inservice calendar is in place to meet rule. 2. An audit of remaining staff training records will be completed for annual inservice hours including dementia care topics, annual infectious disease training and HCBS training per rule. Executive Director and Business Office Coordinator will be provided education as it relates to requirements in rule. The Business Office Coordinator will routinely monitor completion of online training courses as well as track inservice hours provided during all associate meetings. 3. Business Office Coordinator and/or designee to audit training files monthly for 2 months then quarterly thereafter to assure compliance. 4. Executive Director, Busines Office Coordinator or designee will be responsible for overseeing that corrections are completed and monitored.

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 instruct residents within 24 hours of admission and re-instruct at least annually, on general safety procedures, evacuation methods, responsibilities during fire drills, designated meeting places outside the building or within the fire safe area in the event of an actual fire and maintain a written record of fire safety training , including content of the training sessions and the residents attending. Findings include, but are not limited to: Review of fire drill and fire and life safety records for 11/2024 through 04/2025 revealed there was no documented evidence of resident instruction within 24 hours of admission or annual fire safety re-instruction. On 05/06/25 at 1:30 pm, Staff 5 (Maintenance Supervisor) stated he instructed residents verbally on admission and confirmed the facility does not have a system for re-instructing residents, at least annually on fire and life safety expectations. On 05/07/25 at 11:50 am, the need to instruct residents within 24 hours of admission and re-instruct, at least annually, on general safety procedures, evacuation methods, responsibilities during fire drills, designated meeting places outside the building or within the fire safe area in the event of an actual fire per the OFC requirements and maintaining a written record of fire safety training , including content of the training sessions and the residents attending was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director/LPN) and Staff 5. They acknowledged the findings.

1. Fire and life safety instruction for current residents is scheduled during next Town Hall meeting on June 16, 2025. 2. Maps with highlighted evacuation routes will be provided to current residents and they will indicate training and understanding via signature on the map. This will be hung on the back of their apartment door for easy visibility. 3. Maintenance Supervisor or designee will conduct random audits weekly for 60 days of resident apartments to ensure that maps are still posted for resident access. Following the initial 60 days, random audits will continue bi-monthly. 4. Executive Director, Maintenance Supervisor or designee will be responsible for overseeing that corrections are completed and monitored.

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 facility was clean and in good repair. Findings include, but are not limited to: Observations of the facility on 05/05/25 showed the following areas in need of cleaning and/or repair: * Handrails throughout the facility had scraped, scratched or worn areas, exposing bare wood in multiple areas; * Tables and chairs in the second floor activities area had scratches and scrapes to the legs and bases, and multiple chair arm rests had the finish worn down or off; * Wood banister on second floor had areas where the finish was worn through, exposing bare wood in multiple areas; * The top of the cabinet near activities area had the finish removed in multiple places, leaving exposed bare wood; and * Multiple chairs, couches and upholstered benches had dark and light stains observed on the fabric of the furniture. *The first floor 100 hall had a strong, pervasive unpleasant odor present throughout survey. Staff 1 (ED) reported she was aware of the smell on the 100 hall and was working to resolve the issues that were causing the odors. The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 and Staff 5 (Maintenance Supervisor) on 05/07/25. They acknowledged the findings.

1. Areas mentioned in the statement of deficiencies in need of cleaning or repair will be repaired, cleaned or replaced. 2. A community walk through will be conducted to determine any other common areas or resident apartments in need of cleaning and repair and work orders created in the electronic work order system for tracking. Current staff will be re-educated on the maintenance order request process by June 13th, 2025. 3. Maintenance Supervisor will conduct weekly walk through of common areas and a sample of resident apartments to identify areas in need of cleaning or repair. This will continue as part of standard operations. 4. Executive Director, Maintenance Supervisor or designee will be responsible for overseeing that corrections are completed and monitored.