OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents for 2 of 3 sampled residents (#s 4 and 5) who required modified diets. The facility’s failure to provide modified diet textures placed them at risk of aspiration, choking, and/or death. Findings include, but are not limited to: 1. Resident 5 moved into the facility in 02/2020 with diagnoses including schizoaffective disorder and diabetes. During the acuity interview on 09/08/26 at 10:12 am, Resident 5 was identified as having had several choking incidences and had been prescribed a “mechanical soft/ soft and bite sized diet.” The resident required one-to-one assistance with feeding to cue for slow and complete chewing of his/her food before swallowing. The resident’s 06/02/26 service plan and 06/02/26 signed prescriber orders were reviewed, observations were made, and interviews were conducted. The following was identified: * Resident 5 had signed orders for a mechanical soft diet with aspiration precautions. A mechanical soft diet consists of foods that are modified by chopping, grinding, blending, or pureeing so they require less chewing effort. Food should be cut into pieces no larger than 1.5 by 1.5 cm. * Resident 5’s service plan stated,"[Resident 5] has seen speech therapy for [his/her] coughing and choking episodes. Therapy informed staff that 1. [Resident 5] fills [his/her] mouth full and does not fully chew [his/her] foods. 2. Because of #1, [s/he] is not breathing properly and inhales food pieces when trying to catch [his/her] breath… cue and encourage [Resident 5] to slow down and breathe between bites, cut [his/her] foods, [and] finish one bite before putting more food in [his/her] mouth.” During a lunch observation on 09/08/26 at 12:28 pm, Resident 5 was served the following food items: * A cheese enchilada, cut into approximately 4 cm pieces; * A scoop of rice; and * A scoop of black beans. The enchilada was not cut to the required size and lacked a sauce or gravy. The resident was observed eating a few bites of the beans before getting up and walking back to [his/her] unit. Resident 5 was not supervised by staff or provided cues during the meal. During a lunch observation on 09/09/26 at 12:05 pm, Resident 5 was served the following food items: * A baked vegetable burger in a dry bun, without condiments or sauce, cut into six pieces approximately 5 cm by 6 cm; * Tater tots with a side dish of ketchup; and * Cole slaw. The veggie patty was not ground or cut up, nor was it moistened as per the prescribed diet texture. The tater tots were not served with the ketchup over them or chopped into smaller pieces, and the cabbage and carrot slices in the coleslaw were not soft or altered for ease of chewing. Under the supervision of care staff, Resident 5 ate all of the vegetable burger, 50% of the tater tots and none of the coleslaw. In an interview on 09/09/26 at 12:41 pm, Staff 6 (MA), who had prepared the lunches that day, stated she had prepared residents’ meals as she had been trained to do. On 09/09/26, Staff 5 (MA) stated she had not received training on how to prepare modified texture diets because all residents who had orders for such a diet had refused to comply and had signed managed risk agreements accepting the consequences of not following the prescribed orders. On 09/09/26 at 12:29 pm, a managed risk agreement regarding refusal to comply with diet orders for Resident 5 was requested. On 09/09/26 at 12:52 pm, Staff 1 (Director of Operations) confirmed there was no documented evidence of the agreement for Resident 5. The facility failed to ensure Resident 5 received the prescribed diet order of mechanical soft and failed to ensure staff had been trained on the prescribed diet texture, which placed the resident at risk for choking, aspiration, and/or death. An immediate plan of correction was requested from Staff 1 (Director of Operations) on 09/09/26 at 3:37 pm. The plan of correction was received and accepted by the survey team on 08/18/26 at 5:50 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation. The need to ensure the facility exercised reasonable precautions against any condition which could threaten the health, safety, or welfare of residents was discussed with Staff 1 on 09/09/26 at 3:51 pm. She acknowledged the findings. 2. Resident 4 was admitted to the facility in 08/2018 with diagnoses including bipolar disorder and diabetes. During the acuity interview on 09/08/26 at 10:12 am, Resident 4 was identified as having a minced and moist diet texture. Staff reported the resident refused to follow the diet. The resident’s 06/23/26 service plan and a 07/16/25 speech-language pathologist (SLP) note were reviewed, observations were made, and interviews were conducted. The following was identified: * The SLP recommended “soft/easy-chew solids (cut into dime-sized pieces or smaller, add extra moisture).” A soft and easy-to-chew diet consists of tender, everyday foods that break apart easily, and does not include hard, tough, chewy, fibrous, or stringy textures. * Resident 4’s service plan indicated Resident 4’s “speech therapy doctor” identified the resident had a “pocket” in the throat that “collect[ed] food and liquids.” The “doctor” recommended eating “soft foods such as a minced and moist texture diet, add extra moisture to solids and chop them, take smaller bites, wash down every bite with a drink, eat and drink slowly. [Resident 4] has requested for staff to not change [his/her] meals” and would let the kitchen know what s/he would or would not eat. Staff were instructed to follow the “minced and moist” sheet in the kitchen, honor Resident 4’s food choice, and cut up the food into smaller pieces as Resident 4 allowed or requested. The service plan noted Resident 4 “mainly eats in [his/her] room.” * During a lunch observation on 09/09/26 at 12:02 pm, Resident 4 was served half of an open-faced sloppy joe on a hot dog bun, tater tots and quartered canned pears, all of which were not cut up into dime-sized pieces and/or did not have added moisture. The served food was not consistent with the soft and easy-to-chew diet. Resident 4 ate in his/her room with the door closed, and staff were not observed to check on the resident during the meal. The resident ate all of the pears and tater tots and a few bites of the sloppy joe meat. In an interview on 09/09/26 at 12:41 pm, Staff 6 (MA), who had prepared lunch on 09/09/26 for residents, stated no diet texture modification was needed for Resident 4 because s/he refused the recommended diet. On 09/09/26, Staff 5 (MA) stated she had not received training on how to prepare modified texture diets because all residents who had orders for such a diet had refused them. On 09/09/26 at 1:30 pm, Staff 2 (RN) acknowledged Resident 4 refused to stop eating salads and “chokes” which required staff intervention with “back blows” as recently as “about a month and a half ago.” She confirmed staff did not perform safety checks when the resident ate meals in his/her room. Resident 4 had a history of choking, difficulty swallowing, and had a recommended modified texture diet. The resident ate most meals in his/her room. The facility failed to implement measures to increase safety while eating, including implementing the recommended diet texture and staff safety checks while eating, placing the resident at risk for choking, aspiration, and or death. An immediate plan of correction was requested from Staff 1 on 09/09/26 at 3:37 pm. The plan of correction was received and accepted by the survey team on 09/09/26 at 5:50 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation. The need to ensure the facility exercised reasonable precautions against any condition which could threaten the health, safety, or welfare of residents was discussed with Staff 1 on 09/09/26 at 3:51 pm. She acknowledged the findings.

1. What actions will be taken to correct the rule violation – A managed risk agreement has been put into place for the resident number 4 who prefers to eat in their room. In addition to the risk agreement resident 4 has agreed to keep their door open while eating. Staff will also make rounds throughout meal time to check on the resident frequently, staff will be observing any signs of choking such as wheezing, repeated coughing, or clutching their throat. For Resident number 5, prior to each meal being served, the staff member preparing the meal will verify the resident's diet order and ensure that all food items have been appropriately modified. Foods will be chopped, ground, mashed, softened, moistened, pureed, or otherwise prepared as required by that resident's specific order which is a mechanical soft. The Administrator or designee will visually verify the affected residents' meals prior to service until staff competency and consistent compliance have been demonstrated. Staff were immediately educated regarding the seriousness of following modified diet orders and the increased risk of choking and aspiration when ordered food textures are not followed. All staff preparing food on 09/09/2026 were trained on Res 5 and Res 1 diet texture. If there is any uncertainty regarding whether a food item meets a resident's ordered texture, the food will not be served until the appropriate nurse/supervisor has been consulted and the correct preparation has been verified. 2. How will the system be corrected so these violations will not happen again; All staff involved in preparing, serving, or assisting residents with meals and snacks will receive training on: ? What a mechanical soft/modified-texture diet means and how foods must be prepared. ? Appropriate and inappropriate foods for modified diets. ? Proper chopping, grinding, mashing, softening, moistening, and other texture-modification techniques. ? Following the individual resident's diet order rather than assuming all modified diets are the same. ? Checking the resident's dietary requirements before preparing and serving meals. ? Choking and aspiration risks associated with serving an incorrect food texture. ? Immediately asking the nurse or Administrator when there is uncertainty regarding a resident's ordered diet or whether a food is appropriate. ? Reporting coughing, choking, difficulty chewing/swallowing, pocketing food, or other swallowing concerns immediately according to facility procedure. Staff will complete the training and demonstrate understanding of appropriate food preparation before independently preparing modified-texture meals, as well as any new diets that may arise. New employees responsible for food preparation or meal service will receive modified- diet training during orientation and before independently preparing meals for residents with modified-texture orders. When a new diet comes in, staff will be trained on that kind of diet by the facility RN. Staff will be educated that If a resident refuses a meal modification they will notify the RN; 3. How often will the area needing correction be evaluated; The Administrator/designee will conduct and document daily meal audits for 14 days, including observation of modified-texture meal preparation and the meal prior to being served. Following successful completion of the initial 14-day monitoring period, audits will be conducted weekly for four weeks. Following the four-week period, audits will be conducted monthly for three months and thereafter as part of the facility's ongoing quality assurance process. Audits will verify that: ? The correct resident is receiving the correct ordered diet. ? The texture of each applicable food item meets the resident's current order. ? Staff can identify residents requiring modified diets. ? Staff understand how the food must be prepared. ? Dietary information and resident orders remain consistent and current. Any deficiency identified during an audit will be corrected immediately before the meal is served. The staff member involved will receive immediate retraining. Repeated failure to follow a resident's prescribed diet may result in additional corrective action consistent with facility policy. 4. Who will be responsible for seeing that the corrections are completed? The Administrator of Riverside Living will have primary responsibility for implementing and overseeing this Plan of Correction. The Administrator, in coordination with the facility nurse and designated management staff, will be responsible for: ? Ensuring resident diet orders are reviewed and accurately communicated. ? Ensuring affected residents immediately receive their prescribed diet textures. ? Completing or assigning staff training. ? Verifying staff competency. ? Conducting and/or reviewing meal audits. ? Ensuring new and changed diet orders are promptly communicated to staff. ? Correcting identified deficiencies immediately. ? Maintaining documentation demonstrating continued compliance. The Administrator will review the monitoring results and ensure that corrective measures remain in place to prevent recurrence.

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 and document what action or intervention was needed for the resident, communicate the action or intervention to staff on each shift and failed to monitor each resident consistent with his/her evaluated needs and service plan for 2 of 2 sampled residents (#s 1 and 3) who experienced short-term changes of condition. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 04/2022 with diagnoses including paranoid schizophrenia. In the acuity interview on 09/08/26 at 10:12 am, the resident was identified as having had a recent fall resulting in transport to the emergency department for evaluation. The resident’s 06/09/26 to 09/08/26 clinical record was reviewed, and the following was revealed: There was no documented evidence the facility determined what action or intervention was needed for the resident, communicated the determined action or intervention to staff on each shift, and/or monitored the resident consistent with evaluated needs for the following short-term changes of condition: * 06/14/26- Unwitnessed fall without injury; * 06/24/26- Unwitnessed fall without injury; * 07/10/26- Change in dose for olanzipine (for psychosis) from 7.5 mg to 10 mg; * 08/20/26- Unwitnessed fall without injury; * 08/23/26- New medication: Anoro Ellipta inhaler (for chronic obstructive pulmonary disease); * 08/28/26- Witnessed fall without injury; * 08/31/26- The resident was sent to the emergency department for urinary tract infection symptoms; * 09/01/26- New medications: Bactrim and Vantin, antibiotics for a urinary tract infection; * 09/02/26- Witnessed fall without injury; and * 09/03/26- Witnessed fall with transport to the emergency department for evaluation. Resident 3’s 07/23/26 service plan did not include prior interventions listed on temporary service plans (TSPs) following two falls on 06/17/26 and 07/12/26 to remind the resident to always use his/her walker when ambulating and to reach back for the chair when sitting. There was no documentation of the resident’s fall risk or prior history of falls. On 09/10/26 at 1:00 pm, Staff 2 (RN) confirmed there was no documentation that actions or interventions were communicated to staff for the repeat falls. On 09/10/26 at 3:05 pm, Staff 1 (Director of Operations) confirmed the lack of monitoring the resident according to evaluated needs, including the effectiveness of interventions for the repeat falls. The need to ensure the facility identified and communicated interventions to staff on all shifts and to ensure residents were monitored consistent with their evaluated needs and service plan for short-term changes of condition was reviewed with Staff 1 and Staff 2 on 09/10/26 at 3:05 pm. They acknowledged the findings. 2. Resident 1 moved into the facility in 01/2026 with diagnoses including diastolic heart failure, chronic obstructive pulmonary disease and hypertension (high blood pressure). The resident’s 06/08/26 to 09/08/26 clinical record was reviewed and the following was revealed: a. There was no documented evidence the facility determined what action or intervention was needed for the resident and communicated the determined action or intervention to staff on each shift for the following short-term changes of condition: * 06/11/26 – “Shaking” following a nebulizer treatment; * 06/15/26 - Seizure activity; * 06/24/26 - Suicidal thoughts; * 06/30/26 – Seizure activity; * 07/30/26 - One time dose of medication: olanzapine 5 mg (for nighttime hallucinations); * 07/31/26 – Increase medication lamotrigrine from 25 mg to 50 mg (for seizure/mood stabilization); * 08/07/26 - Start new medication olanzapine 5 mg (for anxiety); * 08/16/26 - Increase medication lamotrigrine from 50 mg to 100 mg; * 08/27/26 – New medication potassium chloride 20 milliequivalent (for heart health); and * 09/05/26 – Unwitnessed fall without injury. On 09/10/26 at 2:45 pm Staff 1 (Director of Operations) confirmed the lack of documentation for the above short-term changes of condition. b. During the acuity interview on 09/08/26 at 10:12 am, Resident 1 was identified as having had a recent fall. Review of Resident 1’s fall record revealed the following: * The 07/23/26 service plan indicated Resident 1 had a history of falls during self-transfers and instructed staff to provide assistance during transfers and to encourage the resident to request assistance prior to attempting to transfer. * On 07/27/26, staff documented the resident had an unwitnessed fall without injury while transferring from the wheelchair to the recliner. There was no documented evidence fall interventions were identified and communicated to staff on all shifts or that interventions were implemented and monitored for effectiveness. * On 08/21/26 staff documented Resident 1 was found on his/her knees by the wheelchair, unable to state what happened other than his/her catheter came out. Interventions identified in the fall investigation included to “[e]ncourage resident to call for assistance.” There was no documented evidence this intervention was reviewed for effectiveness. * On 08/31/26 staff documented Resident 1 had an unwitnessed non-injury fall and was found on the floor by his/her wheelchair. Interventions identified on the fall investigation included “encourage resident to call for help.” There was no documented evidence prior interventions were reviewed for effectiveness. On 09/10/26 at 2:30 pm, Staff 2 (RN) acknowledged prior fall interventions were not reviewed for effectiveness and new interventions were not determined and communicated to staff on all shifts. The need to ensure the facility identified and communicated interventions to staff on all shifts and to ensure residents were monitored consistent with their evaluated needs and service plan was discussed with Staff 1 and Staff 2 on 09/10/26 at 3:35 pm. They acknowledged the findings.

1). For Residents 1 and 3, the RN immediately completed a comprehensive review of all recent changes of condition identified in the SOD. Each event—such as falls, medication changes, seizure activity, behavioral concerns, and new symptoms—was evaluated using the facility’s Change of Condition Evaluation form. The RN ensured that every event had a documented assessment, that appropriate interventions were identified, and that a Temporary Service Plan/Interim Service Plan (TSP/ISP) was created whenever short-term monitoring was required. When interventions needed to continue beyond short-term monitoring, the RN updated the residents’ Service Plans to reflect ongoing needs. As part of this corrective action, the RN also reviewed each intervention for effectiveness, particularly those related to fall prevention and weight changes. If an intervention was found to be ineffective—such as continued falls despite cueing or ongoing weight fluctuations despite dietary adjustments—the RN immediately revised the intervention, updated the TSP/ISP or Service Plan, and communicated the new instructions to caregivers on all shifts. Caregivers were notified of all interventions through written shift communication, verbal handoff review, and updated service plan pages placed in the care binder. This ensured that both residents immediately received consistent monitoring, responsive adjustments, and support aligned with their evaluated needs. 2). Moving forward, the facility has implemented a standardized Change of Condition Response System designed to ensure timely identification, documentation, communication, and monitoring of all changes of condition. The administrator has created a “Change of Condition Trigger List,” posted at all workstations, reminding staff of the specific events that require documentation and RN review, including any fall (witnessed or unwitnessed), any medication change, any new symptom, any behavioral change, any seizure activity, any new complaint from the resident, and any weight change. The facility has also implemented a policy requiring mandatory RN review within 24 hours of any event on the trigger list. After each event, the RN completes a Change of Condition Evaluation, identifies interventions, creates a TSP/ISP when monitoring is needed, and updates the resident’s service plan when interventions extend beyond short term monitoring. As part of this new process, the RN evaluates the effectiveness of each intervention during monitoring and weekly audits. If an intervention is not preventing recurrence or improving the resident’s condition, the RN revises the intervention immediately and updates the resident’s documentation accordingly. All caregivers are informed of updated interventions through written shift communication, verbal handoff review, and updated service plan pages placed in the care binder. Additionally, the facility has implemented a new shift to shift handoff report to ensure staff remain informed of daily resident events. Although written shift communication is used to notify caregivers immediately of new interventions, the facility ensures compliance with OAR requirements by maintaining resident specific documentation in the permanent record. Because written shift communication may contain multiple residents’ names, the RN creates a resident specific Change of Condition Evaluation, a TSP/ISP with monitoring instructions, and progress notes documenting monitoring and resolution. When interventions extend beyond short term monitoring, the resident’s service plan is updated accordingly. These resident specific documents are placed directly in the resident’s chart and serve as the official record of the change of condition, ensuring full compliance with OARs. Written shift communication is used solely for immediate staff notification, while the TSP/ISP, progress notes, and service plan updates fulfill the regulatory requirement for documentation within the resident’s record. To reinforce this process, quarterly training has been added to educate staff on what constitutes a change of condition, how to document it, how to communicate it, and how to monitor residents appropriately. 3). To ensure ongoing compliance, the RN conducts weekly audits reviewing all change of condition events, documentation completeness, intervention determination, communication to all shifts, and monitoring notes for effectiveness. These weekly audits allow the RN to identify any gaps in documentation or communication and correct them promptly. During these audits, the RN also evaluates whether interventions; particularly fall related interventions and those addressing weight changes, are effective, and revises them immediately if they are not. In addition to the RN’s weekly review, the administrator performs a monthly audit of all charts containing change of condition events to ensure that evaluations, TSP/ISP, service plan updates, and monitoring notes are present and complete. Quarterly training further reinforces compliance by ensuring staff remain knowledgeable about the process and their responsibilities. 4). Oversight of the new process is shared among the RN, the administrator, and the caregiving team. The RN is responsible for completing all change of condition evaluations, creating TSP/ISPs, updating resident service plans, conducting weekly audits, reviewing intervention effectiveness, and providing quarterly training. The administrator oversees overall compliance, performs monthly audits, ensures staff accountability, and maintains the Change of Condition Trigger List at all workstations. Caregivers and medication aides are responsible for identifying and reporting changes of condition, implementing interventions, documenting monitoring, and participating in shift to shift communication to ensure continuity of care. Together, these roles ensure that the system operates consistently, responsively, and in full compliance with OAR.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment that documented findings, resident status, and interventions made as a result of the assessment was completed for 1 of 1 sampled resident (#1) who experienced significant weight changes. Findings include, but are not limited to: Resident 1 moved into the facility in 01/2026 with diagnoses including diastolic heart failure, chronic obstructive pulmonary disease and hypertension (high blood pressure). Weight records, dated 03/10/26 through 09/08/26, were reviewed and indicated the resident’s weight increased from 215.2 pounds to 243.3 pounds between 08/06/26 and 09/04/26, or 13.06% in one month. The weight gain constituted a significant change of condition which required an RN assessment. Resident 1’s weight on 09/08/26 was 244.9 pounds. An interview with Staff 2 (RN) on 09/09/26 at 1:30 pm indicated she notified the resident’s provider on 08/26/26 when the resident was observed to be more “puffy” in the face and extremities and received an order for daily weights and a three-day higher dose of a diuretic. The RN acknowledged there was no RN assessment that documented the resident’s significant weight gain and included findings and resident status. The need to ensure an RN assessment was completed which documented findings and resident status was discussed with Staff 1 (Director of Operations) and Staff 2 on 09/10/26 at 3:35 pm. The staff acknowledged the findings.

1). For resident #1 identified in the citation, the RN immediately reviewed their recent weight logs, vital signs, and clinical records to determine whether a significant change of condition had occurred. The RN completed a full resident assessment, documented the findings, and updated the resident’s Service Plan to reflect the assessment results, monitoring needs, and any new interventions ordered by the provider. Weight tracking frequency was adjusted when needed, and monitoring instructions were added to ensure staff were consistently observing the resident’s nutritional status and overall condition. Medication staff responsible for weight monitoring were re educated on the reporting thresholds for significant weight changes to ensure timely RN notification. These corrective actions ensured that the residents cited in the deficiency received the required RN assessment and that their service plans accurately reflected their current needs. 2). Moving forward, the facility has implemented a structured process to ensure that RN assessments occur promptly whenever a resident experiences a significant weight change or any other event that may indicate a significant change of condition. The RN will review all residents’ weekly vital signs and weight logs and complete a resident assessment for any resident who demonstrates a significant weight change. The Service Plan will be updated to reflect the RN’s assessment, including any identified monitoring needs, changes in weight tracking frequency, or new interventions ordered by the provider. To prevent recurrence of this deficiency, the facility will use the “Change of Condition Trigger List” to identify events requiring RN assessment within 24 hours. This list includes significant weight changes, and staff are required to notify the RN immediately when such changes occur. If an RN is not physically present in the building, staff may contact the on call RN 24/7 to ensure timely assessment and intervention. 3). To ensure ongoing compliance, the RN conducts weekly audits that include a review of all weekly weight logs for accuracy, completeness, and identification of significant changes. During these audits, the RN verifies that assessments were completed when required and that Service Plans were updated appropriately. The administrator performs a monthly audit of all residents who experienced any change of condition, including significant weight changes, to ensure that RN assessments, documentation, and service plan updates were completed according to regulatory requirements. These ongoing audits ensure that the process remains consistent, timely, and compliant. 4).Oversight of this process is shared between the RN and the administrator. The RN is responsible for reviewing weekly vital signs and weight logs, completing resident assessments for significant weight changes, updating Service Plans, and conducting weekly audits. The administrator is responsible for ensuring overall compliance, performing monthly audits, and ensuring that staff follow reporting thresholds and the Change of Condition Trigger List. Medication staff and caregivers are responsible for accurate weight monitoring, timely reporting of significant changes, and implementing any new interventions identified by the RN. Together, these roles ensure that the system operates consistently and in full compliance with OARs.

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 residents' MARs were accurate regarding following resident-specific parameters and instructions for PRN medications for 1 of 2 sampled residents (#s 1) whose MARs were reviewed. Findings include, but are not limited to: Resident 1 moved into the facility in 01/2026 with diagnoses including diastolic heart failure, chronic obstructive pulmonary disease and hypertension (high blood pressure). The resident’s 08/01/26 through 09/08/26 MAR and physician’s orders were reviewed. The following was identified: a. Resident 1 had the following PRN medications with no instructions on which to take first: * Acetaminophen 325 mg tablet, two tablets every six hours as needed for pain; * Ibuprofen 600 mg tablet, one tablet every eight hours as needed for pain; * Methocarbamol 500 mg, 1 tablet four times daily as needed for muscle spasms; * Lidocaine cream 5%, one gram to low back four times daily as needed for lower back pain; * Polyethylene glycol 3350, 17 grams/scoop as needed for constipation; * Bisacodyl 10 mg suppository, one as needed for constipation; * Albuterol 90 mcg inhaler, two puffs every four hours as needed for shortness of breath/wheezing; and * Albuterol sulfate 0.63 mg/mL nebulizer, one vial every four hours for shortness of breath/wheezing. b. The MAR indicated the resident’s blood pressure and heart rate were taken daily, prior to administration of metoprolol 25 mg (for cardiovascular health). The MAR lacked resident-specific parameters of when to notify the physician when the blood pressure and/or heart rate values were too high or too low. c. The resident had been prescribed Zaditor eye drops 0.035% (for inflammation), one drop in each eye twice daily for 21 days. The MAR indicated the “end” date on 09/10/26, which equated to 19 days of administration, not 21. On 09/10/26 at 2:35 pm, Staff 1 (Director of Operations) acknowledged the end date should be on 09/12/26, corrected the MAR and confirmed the medication would be administered until 09/12/26. The need to ensure the MAR was accurate regarding resident-specific parameters and instructions for administration of PRN pain medication was reviewed with Staff 1 and Staff 2 on 09/10/26 at 3:35 pm. They acknowledged the findings.

1). For Resident 1, the RN conducted an immediate, resident specific review of their MAR to correct all issues identified in the citation. Each PRN medication was examined to ensure clear, individualized parameters were present, including which PRN medication should be used first, when escalation was required, and when the RN or prescriber must be notified. For the residents medications requiring monitoring—such as blood pressure, heart rate, or other vital parameters—were updated to include resident specific instructions for when to hold the medication and when to notify the RN or provider. The RN also reviewed all medications with defined durations to ensure accurate start and end dates were entered in the MAR. Any missing, unclear, or incorrect parameters for Resident 1 were corrected immediately. These actions ensured that the MAR for the cited resident were fully accurate, complete, and compliant with prescriber orders and regulatory requirements. 2). Moving forward, the facility has strengthened its medication order verification process by adding a “PRN Parameters” checkpoint to the triple check system used when new medication orders are received. This ensures that every PRN medication is reviewed for required parameters before being entered into the MAR. The facility is also implementing a standardized PRN pain ladder for all residents who have PRN pain medications. This pain ladder will be individualized per resident and entered directly into the MAR, clearly outlining which PRN pain medication should be used first, when escalation is appropriate, and when the RN must be notified. Medication staff and RNs will be retrained on PRN parameter requirements, pain ladder use, MAR accuracy expectations, documentation standards, and when to notify the RN or prescriber. This enhanced process ensures that all PRN medications are entered with complete, resident specific instructions and that staff understand how to administer and escalate PRN medications safely and consistently. 3).To ensure ongoing compliance, the facility has implemented a weekly MAR audit for the first 90 days, followed by monthly audits thereafter. During these audits, the RN reviews all MARs to verify that PRN parameters are present, individualized, and accurate; that PRN pain ladder instructions are clearly documented; that monitoring parameters such as blood pressure and heart rate are included when required; and that all medication end dates match prescriber orders. These audits also ensure that no PRN medications are missing instructions and that all MAR entries remain compliant with regulatory requirements. Any discrepancies identified during audits are corrected immediately, and staff receive follow-up education when needed. 4). Oversight of this process is shared between the RN, the administrator, and the medication staff. The RN is responsible for verifying PRN parameters, creating individualized PRN pain ladders, ensuring MAR accuracy, and conducting weekly and monthly audits. The administrator oversees overall compliance, ensures staff accountability, and monitors audit outcomes to identify trends or training needs. Medication staff are responsible for accurately entering new orders, following PRN parameters and pain ladder instructions, and notifying the RN or prescriber when required. Together, these roles ensure that the MAR remains accurate, complete, and fully compliant with OAR.

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 supportive devices with restraining qualities were assessed thoroughly by an RN, PT, or OT prior to use, evaluated at least quarterly, and the facility informed the individual of the risks and benefits associated with the device, documented other less restrictive alternatives were evaluated prior to the use of the device, instructed caregivers on the correct use and precautions related to use of the device, and included information regarding the use of the device in the resident’s service plan for 2 of 2 sampled residents (#s 1 and 3) who were observed with a side rail. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 04/2022 with diagnoses including paranoid schizophrenia. The resident was identified in the acuity interview on 09/08/26 on 10:12 am as using a side rail for mobility. The resident’s clinical 06/09/26 to 09/08/26 record was reviewed, observations were made, and interviews with the resident and staff were conducted. The following was identified: On 09/08/26 at 1:20 pm, observations of the resident’s room revealed a half-length side rail on the bed in the raised position. Resident 3 stated s/he used the rail to feel steady during transfers and “it helps a lot.” A current assessment of the side rail was requested on 09/08/26 and an incomplete copy was received at 1:58 pm. Staff 2 (RN) stated she could only find the first page of the assessment, which had been completed “sometime in October of 2025,” but the document did not include a signature or the date of the assessment. Staff 2 also confirmed there was no quarterly evaluation for the side rail. The side rail assessment provided failed to document the following: * The resident specifically requested or approved of the device and the facility informed the individual of the risks and benefits associated with the device; * Other less restrictive alternatives were evaluated prior to the use of the device; and * Caregivers were instructed on the correct use and precautions related to use of the device. Additionally, the resident’s most recent service plan dated 07/23/26 did not include any instructions for staff as to how the side rails were to be used, monitored for safety, and to whom any malfunctions should be reported. The need to ensure an assessment of assistive devices with restraining qualities was completed at the required intervals and included all required elements was discussed with Staff 1 (Director of Operations) and Staff 2 on 09/10/26 at 3:05 pm. They acknowledged the findings. 2. Resident 1 moved into the facility in 01/2026 with diagnoses including diastolic heart failure, chronic obstructive pulmonary disease and hypertension (high blood pressure). The resident was identified in the acuity interview on 09/08/26 at 10:12 am as using a side rail for mobility. Observations of the resident and the resident's room on 09/08/26 at 1:57 pm identified Resident 1 had two half-length side rails in the up position on each side of the bed. Resident 1 indicated the rails were helpful for positioning in bed and during transfers. A current assessment for the side rails was requested on 09/08/26, and a copy of the initial assessment was provided on 09/08/26 at 1:35 pm. Review of the side rail assessment identified the following: * The assessment had been completed by Staff 2 (RN) but lacked a date to indicate when it had been assessed; and * There was no documented evidence regarding the risks versus benefits of the device for the resident, other less restrictive alternatives were evaluated prior to the use of the side rails or that caregivers were instructed on the correct use of and precautions for the device. Additionally, review of the resident’s most recent service plan and temporary service plans did not include any instructions related to monitoring side rail use and whom to report to if there was a malfunction. During an interview on 09/08/26 at 1:35 pm, Staff 2 confirmed she completed the assessment “the first part of February” but forgot to put a date. She also acknowledged a quarterly evaluation had not been completed. The need to ensure an assessment of assistive devices with restraining qualities was completed with the documentation requirements for the use of such devices, and completed quarterly, were discussed with Staff 1 (Director of Operations) and Staff 2 on 09/10/26 at 3:35 pm. They acknowledged the findings.

1).For Resident 1 and Resident 3, the RN immediately completed a full assistive device safety assessment to address the deficiencies identified in the citation. Each resident’s side rail use was evaluated to ensure compliance with OAR requirements, including confirming that the device was clinically appropriate, that risks and benefits had been considered, and that less restrictive alternatives were evaluated. The RN documented the assessment findings and updated each resident’s Service Plan to include clear instructions for safe use of the side rails, monitoring expectations, and procedures for reporting any malfunction or safety concerns. Caregivers were notified of the updated instructions through written communication and verbal review. Additionally, all staff received re-education on supportive devices, including correct use, entrapment risks, daily monitoring expectations, and documentation requirements. These corrective actions ensured that both cited residents had complete, accurate, and compliant assessments and service plans reflecting safe and appropriate use of their supportive devices. 2). Moving forward, the facility has implemented a structured process to ensure that all supportive devices with restraining qualities are assessed, documented, and monitored in accordance with OAR requirements. An RN assessment checklist has been implemented to ensure that assistive device safety assessments are completed quarterly for any resident using a supportive device. A facility-wide annual training will be conducted for all staff, covering supportive devices versus restraints, correct use of supportive devices, required documentation, safety precautions, and entrapment risks. All new hires will receive this training during orientation to ensure competency from the start. Additionally, before any supportive device is installed, the facility will use a “pre-approval checklist” requiring documentation of a risk-versus-benefit discussion, completion of an RN/PT/OT assessment, evaluation of less restrictive alternatives, and an immediate update to the resident’s Service Plan. This process ensures that supportive devices are only used when clinically appropriate and fully documented. 3). To ensure ongoing compliance, the RN performs a weekly visual safety check of all supportive devices currently in use. During these checks, the RN verifies that each device is functioning properly, that no entrapment risks are present, and that a current assistive device safety assessment is on file. The administrator conducts monthly supportive device audits to ensure that assessments, service plan updates, and monitoring documentation are complete and accurate. These audits allow the facility to identify any gaps in documentation or staff practice and correct them promptly. Quarterly RN assessments and annual staff training further reinforce compliance and ensure the system remains consistent and effective. 4). Oversight of this process is shared between the RN, the administrator, and the caregiving team. The RN is responsible for completing quarterly assistive device safety assessments, performing weekly visual safety checks, updating Service Plans, and providing staff education on supportive devices. The administrator oversees overall compliance, performs monthly audits, ensures staff accountability, and verifies that pre approval checklists are completed before any supportive device is installed. Caregivers and medication aides are responsible for daily monitoring of supportive devices, reporting any malfunction or safety concerns immediately, and following all service plan instructions related to safe use. Together, these roles ensure that supportive devices are used safely, appropriately, and in full compliance with OAR