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 document staff instructions or interventions as part of the resident record, with weekly progress noted until the condition resolved, for 2 of 2 sampled residents (#s 1 and 2) who were reviewed for short-term changes of condition. Findings include, but are not limited to: On 09/08/26, during the acuity interview with Staff 1 (Administrator) and Staff 2 (Facility RN), they stated short-term changes of condition were communicated to staff via the Communication Report. This documentation was reviewed during survey and determined not to be part of the resident record. During interviews on 09/09/26 and 09/10/26 with Staff 4 (CG) and Staff 5 (MT), they stated residents’ short-term changes of condition were communicated to them verbally during shift change or on the Communication Report. 1. Resident 2 was admitted into the facility in 09/2025 with diagnoses including type 2 diabetes mellitus and atrial fibrillation. The resident's clinical record, including progress notes dated 06/08/26 through 09/08/26, and facility incident reports were reviewed, and interviews with facility staff were conducted between 09/08/26 and 09/10/26. From 07/26/26 to 08/27/26, Resident 2 was identified to have multiple non-injury falls, hospital visits, and medication changes. There was no documented evidence the facility communicated instructions or interventions to staff, made the documentation part of the resident record, and monitored the resident with documented progress at least weekly until the short-term change of condition resolved. 2. Resident 1 was admitted into the facility in 11/2022 with diagnoses including depression and irritable bowel syndrome. The resident's clinical record, including progress notes dated 06/08/26 through 09/08/26, were reviewed, and interviews with facility staff were conducted between 09/08/26 and 09/10/26. From 06/10/26 to 09/08/26, Resident 1 was identified to have multiple medication changes, one skin concern, and ostomy issues. There was no documented evidence the facility communicated instructions or interventions to staff, made the documentation part of the resident record, and monitored the resident with documented progress at least weekly until the short-term change of condition resolved. The need to ensure the facility documented staff instructions or interventions as part of the resident record, with weekly progress noted until the condition resolved was reviewed, was discussed with Staff 1, Staff 2, and Staff 3 (Assistant Administrator/LPN) on 09/10/26 at 2:20 pm. They acknowledged the findings and no further documentation was provided.

1. The Administrator & Facility Nurse have created a detailed training check list for all staff to complete upon hire. The check list includes: the Compliance Series: Understanding Changes of Condition for CBC Facilities in Oregon. We created new policies and steps to insure that all staff can report a Change of Condition. New TCC forms created & in place. All staff will be re-trained with the new policy/procedures, and forms. 2. The Administrator & RN will make sure the trainings are completed & staff are signed off. All new hires will be trained and checked off. Staff that continues to not meet the Change of Condition protocal standard will work with RCA Leads, until success/understanding is reached. 3.Then each week on Thursdays, the Nurse will review all the TCC forms/sign off if completed. Administrator will meet with RCA Leads on Friday's & Monday's to make sure staff is reporting in TCC binder daily and documentation is entered in PointClick Care. 4. RN & Administrator will ensure all Change of Conditions are completed and properly tracked daily/weekly. All employee training will be in compliance by 11/9/26.