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 interview and record review, it was determined the facility failed to ensure a significant change of condition assessment was completed by the RN, which included findings, resident status, and interventions made as a result of the assessment for 1 of 1 sampled resident (# 2) who experienced significant changes of condition for severe weight loss and pressure ulcer. Findings include, but are not limited to: Resident 2 moved into the facility in 11/2021 with diagnoses including atrial fibrillation and hypertension. During the acuity interview on 12/08/25, staff reported Resident 2 had weight loss, skin issues (edema), and was receiving hospice services. The resident’s record was reviewed, and interviews with staff were conducted. The following was identified: a. Staff documented the following weights: * 06/22/25: 98.0 pounds; * 07/27/25: 98.0 pounds; * 08/25/25: 101.4 pounds; * 09/29/25: 98.6 pounds; * 10/27/25: 93.0 pounds; * 11/24/25: 91.4 pounds; and * 12/11/25: 93.4 pounds (requested during survey). From 08/25/25 through 11/24/25, the resident experienced a weight loss of 10.0 pounds, or 9.86% of his/her total body weight in 90 days. The weight loss constituted a significant change of condition and required an RN assessment. There was no documented evidence of an RN assessment for the significant change of condition related to the severe weight loss that included RN findings, resident status, and interventions made as a result of the weight loss. In an interview at 2:45 pm on 12/11/25, Staff 2 (RN) acknowledged no significant change of condition assessment had been completed. b. An outside provider note on 11/05/25 indicated the resident had a stage 2 pressure ulcer to the buttocks, which constituted a significant change of condition requiring an RN assessment. There was no documented evidence of an RN assessment for the significant change of condition related to the pressure ulcer. On 12/11/25 at 2:45 pm, Staff 2 (RN) acknowledged no assessment had been completed. The need to ensure an RN assessment was completed for residents who experienced a significant change of condition, including findings, resident status, and interventions made as a result of the assessment, was reviewed with Staff 1 (ED) on 12/11/25 at 3:30 pm. She acknowledged the findings. No additional documentation was provided.

*Odd Fellows Clinical Team will hold a clinical drill down and IDT every Thursday at 11am. The clinical team will review all residents on Hospice, change of condition, upcoming care plan updates, the nursing skin log, ABST, all alerts, and the last 7 days incident reports. The E.D will be present at each drill down to ensure completion. *An RCC check was added to our 24 hour process. The RCC check includes: 1. Notifying RN of any outside provider notes where pressure wounds or diabetic wounds are documented. 2. RCC reviews all new PRN medications and ensures order of administration for all like PRN's, perameters are in place for all new PRN's, and documenting in MAR weather or ot the resident is able to self direct the need for the PRN or not. RCC will alert the LN of need for direction on medication orders as needed. 3. Rcc will check the alert log to ensure all new medications have been added to the log. *Executive Director will conduct an audit each Friday of all RN change of condition notes to ensure all required documantion has been charted. *RN was provided with a copy of OAR 411-054-0045 fir reference. A quick list was created to keep in the from of the change of condition log binder. *RN, LPN, and ED to conduct a monthly weight the first week on the month, for the previous month to ensure all residents with significant weight loss are placed o the change of condition log, monitored and documented weights are completed weekly.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure MARs had resident-specific parameters for PRN medications and clear instructions to staff for 1 of 1 sampled resident (#6) who received PRN pain medications. Findings include, but are not limited to: Resident 6 was admitted to the facility in 11/2004 with diagnoses that included fractures and chronic pain. The resident's 11/01/25 through 12/08/25 MARs were reviewed and revealed the following: * Resident 6's MARs revealed multiple PRN pain medications that lacked parameters for use and clear instructions to unlicensed staff. In an interview with Staff 14 (RCC) at 11:30 am on 12/11/25, she acknowledged the lack of parameters for PRN pain medications. The need to ensure medications had clear parameters and instructions for staff when more than one PRN medication was prescribed for the same condition was reviewed with Staff 1 (ED) on 12/11/25 at 2:10 pm. She acknowledged the MARs were not accurate.?

*A report for all PRN medications was printed for all residents. Each RCC will request perameters for the RN or resident PCP and update each PRN in the MAR. LPN will run a monthly report to ensure all PRN perameters have been added.-RN or ED to audit this upon completion *New RCC check in place in the 24 hour process, to include the following: RCC reviews all new PRN medications and ensures order of administration for all like PRN's, perameters are in place for all new PRN's, and documenting in MAR weather or ot the resident is able to self direct the need for the PRN or not. RCC will alert the LN of need for direction on medication orders as needed. *RCC's to bring their 24 hour binder to daily stand up. A review of each new medication with be conducted during the clinical portion of stand up. ED to audit the new processes weekly to ensure efficiaency and effectiveness.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the ABST was updated when a resident moved in for 1 of 1 sampled resident (#5); with a significant change of condition for 2 of 2 sampled residents with significant changes of condition (#s 2 and 6); and no less than quarterly at the same time the resident's service plan was updated for 4 of 4 sampled residents (#s 1, 3, 4, and 6) and multiple unsampled residents. Findings include, but are not limited to: The facility’s ABST data was reviewed on 12/09/25 and revealed the following: a. Resident 5 moved into the facility on 10/14/25, and there was no documented evidence the ABST data had been updated prior to move-in or at the same time as the resident’s 30-day service plan update on 11/08/25. b. Resident 2 experienced significant changes of condition on 10/27/25 and 11/05/25, and there was no documented evidence the ABST data had been updated. c. Resident 6 experienced a significant change of condition on 10/02/25, and there was no documented evidence the ABST data had been updated. d. Four sampled residents (#s 1, 3, 4, and 6) and multiple unsampled residents lacked documented evidence the ABST data was updated quarterly at the same time as the resident's service plan. During an interview on 12/09/25 at 2:05 pm, Staff 1 (ED) acknowledged the ABST evaluations had not been completed or updated according to the required schedule. The need to ensure resident ABST evaluations were updated as required by rule, in order to determine an accurate staffing plan, was discussed with Staff 1 on 12/09/25 at 2:05 pm. She acknowledged the findings.

*Odd Fellows Clinical Team will hold a clinical drill down and IDT every Thursday at 11am. The clinical team will review all residents on Hospice, change of condition, upcoming care plan updates, the nursing skin log, ABST, all alerts, and the last 7 days incident reports. The E.D will be present at each drill down to ensure completion. During IDT we create a weekly care plan update schedule. After the care plan has been completed, the RCC will update the residents ABST to ensure accurancy. The ED will preform an audit of the prior weeks care plans and ABST each Wednesday to ensure completion. A training was done by ED on 12/15/2025 to train the RCC's on how to capture the update date correctly in the ODHS ABST tool.

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. Findings include, but are not limited to: A tour of the facility on 12/08/25 identified the following: Seven exit doors were observed on the first and second floor each. None of the exit doors had an alarm or other system to alert staff when residents exited the building. In an interview at 10:48 am on 12/09/25, Staff 6 (Assistant Maintenance Director) confirmed the lack of alarm on any of the building’s exit doors. The need to ensure exit doors were equipped with an alarming device or other acceptable system was discussed with Staff 1 (ED) on 12/09/25 at 3:26 pm. She acknowledged the findings.

12/10/2025 an order was placed for GE Personal Security Window and Door Alarms. Upon delivery The Assistant Facilities Director will place one on each exit door in the facility. The Facilities Director will preform an audit to ensure completion. A monthly schedule was created for the maintence team to change the batteries on every alarm, each month. The team member must sign off upon completion. The Facilites Director will oversee this task for completion each month.