Print Inspection: CHOW000428

OAR 411-054-0034 (1-6) Resident Move-in and Eval: 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 include the following information: (A) Prior living arrangements; (B) Emergency contacts; (C) Service plan involvement - resident, family, and social supports; (D) Financial and other legal relationships, if applicable, including, but not limited to:(i) Advance directives;(ii) Guardianship;(iii) Conservatorship; and(iv) Power of Attorney. (E) Primary language; (F) Community connections; and (G) 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) 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).(b) 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.(c) 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.(d) Cognition, including:(A) Memory;(B) Orientation;(C) Confusion; and(D) Decision-making abilities.(e) Personality, including how the person copes with change or challenging situations.(f) Communication and sensory abilities including:(A) Hearing;(B) Vision;(C) Speech;(D) Use of assistive devices; and(E) Ability to understand and be understood.(g) 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.(h) Independent activities of daily living including:(A) Ability to manage medications;(B) Ability to use call system;(C) Housework and laundry; and(D) Transportation.(i) Pain pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort.(j) Skin condition.(k) Nutrition habits, fluid preferences, and weight if indicated.(l) List of treatments type, frequency, and level of assistance needed.(m) Indicators of nursing needs, including potential for delegated nursing tasks.(n) 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.(o) 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. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure resident move-in evaluations addressed all required elements and quarterly evaluations were the foundation used to develop residents' quarterly service plan, including documentation relevant to the residents' needs and current condition for 2 of 2 sampled residents (#s 1 and 4) whose evaluations were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 07/2022 with diagnoses including type 2 diabetes mellitus, chronic obstructive pulmonary disease, chronic pancreatitis, and chronic respiratory failure. The resident’s record was reviewed, and interviews were conducted. The following was identified: Resident 4’s most recent evaluation used to develop his/her service plan was dated 04/21/24. The resident was discharged from the emergency department and hospital on multiple occasions between 07/12/24 and 09/21/24 with new diagnoses including: * Allergic reaction to cortisone injection; * Osteoarthritis and arthropathy; * Knee effusion; * Knee pain and ambulatory disfunction; * Left flank pain; * Chest pain and hyperglycemia; * Gastrointestinal illness; and * Hematuria and constipation. The facility lacked documented evidence the resident was evaluated relevant to his/her needs and current conditions after returning to the facility. On 09/26/24 at 10:56 am, Staff 27 (Area Director of Nursing) confirmed the last evaluation completed for Resident 4 was dated 04/21/24. The need to ensure evaluations were completed and was the foundation used to develop residents' service plans, including documentation relevant to the residents' needs and current condition was reviewed with Staff 1 (ED) and Staff 27 on 09/27/24 at 11:23 am. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 08/2024 with diagnoses including pneumonia due to Coronavirus and type 2 diabetes. Review of the initial evaluation dated 08/04/24 revealed the following elements were missing: *Personality: including how the person copes with change or challenging situations; and *Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting and room temperature. The need to ensure the initial evaluation included all of the required elements was discussed with Staff 1 (ED) and Staff 27 (Area Director of Nursing) on 09/27/24 at 10:05 am. They acknowledged the findings.

1) Resident 1 and 4 will have an evaluation completed with any changes and all elements included. The evaluation tool was audited and updated to include all elements. 2) Resident care coordinators, nursing, and administrator have a system where the evaluation is completed first and audited to ensure all elements are included. This system will be for new admissions, within 30 days of move-in, quarterly and with any significant change in condition. A move-in checklist will be utilized for any new residents. 3) At move in, 30-days, quarterly, and with significant change of condition. 4) Executive Director

OAR 411-054-0034 (1-6) Resident Move-in and Eval: 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 include the following information: (A) Prior living arrangements; (B) Emergency contacts; (C) Service plan involvement - resident, family, and social supports; (D) Financial and other legal relationships, if applicable, including, but not limited to:(i) Advance directives;(ii) Guardianship;(iii) Conservatorship; and(iv) Power of Attorney. (E) Primary language; (F) Community connections; and (G) 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) 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).(b) 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.(c) 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.(d) Cognition, including:(A) Memory;(B) Orientation;(C) Confusion; and(D) Decision-making abilities.(e) Personality, including how the person copes with change or challenging situations.(f) Communication and sensory abilities including:(A) Hearing;(B) Vision;(C) Speech;(D) Use of assistive devices; and(E) Ability to understand and be understood.(g) 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.(h) Independent activities of daily living including:(A) Ability to manage medications;(B) Ability to use call system;(C) Housework and laundry; and(D) Transportation.(i) Pain pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort.(j) Skin condition.(k) Nutrition habits, fluid preferences, and weight if indicated.(l) List of treatments type, frequency, and level of assistance needed.(m) Indicators of nursing needs, including potential for delegated nursing tasks.(n) 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.(o) 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. This Rule is not met as evidenced by:

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, were readily available to staff, and provided clear direction regarding delivery of services for 5 of 6 sampled residents (#s 1, 2, 3, 4, and 6) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 08/2024 with diagnoses including pneumonia due to Coronavirus and type 2 diabetes. Observations of the resident, interviews with staff, Resident 1 and review of the most current service plan, dated 08/04/24 with updates dated 09/23/24, and interim service plans, dated 08/05/24 through 09/14/24 revealed the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas: * Transferring status; and * Diet status. The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (ED) and Staff 27 (Area Director of Nursing) on 09/27/24 at 10:05 am. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 10/2022 with diagnoses including multiple sclerosis and chronic obstructive pulmonary disorder. Observations of the resident, interviews with staff, Resident 3, and review of the most current service plan, dated 04/22/24 with updates dated 07/09/24, and interim service plans, dated 06/23/24 through 09/16/24 showed the service plan was not reflective of the resident’s current care needs and/or did not provide clear direction to staff in the following areas: * Level of family involvement pertaining to resident care and oversight; * Oxygen use; * Vitals monitoring pertaining to daily weights; and * Home health involvement. Additionally, Resident 6's service plan was not available to staff on 09/24/24 or on 09/25/24. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 3 (RCC) on 09/25/24 at 1:21 pm. They acknowledged the findings. 3. Resident 6 was admitted to the facility in 10/2023 with diagnoses including unspecified diastolic (congestive) heart failure, dementia, and anxiety. The resident's service plan, dated 07/17/24, interim service plans, dated 06/11/24 through 09/23/24, and progress notes, dated 06/23/24 through 09/19/24, were reviewed. Resident 6 was observed and staff were interviewed. The service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas: * Customary sleeping routine including napping; * Which activities Resident 6 needed reminders for; * Leisure activities; * Daily weights and what to monitor for relating to weight gain; * Assistance needed with toileting and frequency including routine related to over the counter medications; * Incontinence products used; * Dressing assistance needed; * Bathing assistance required, including the resident's bathing schedule; * Transfer assistance needed; * Mobility devices used; * Escorts to the dining room for meals including the toileting routine prior and after each meal; * Which over the counter medications the resident had in his/her apartment and where they were located; * Ability to use call pendent versus when spouse use the resident's call pendent to get assistance; * Pain which included over the counter medications and non-pharmaceutical interventions; * Stint removal and placement every six months and any resident specific direction to staff; * What staff should monitor for relating to urinary tract infections; * Finger and toenail care; and * Fall interventions including frequency of safety checks. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 27 (Area Director of Nursing) on 09/27/24 at 10:05 am. They acknowledged the findings. 4. Resident 2 was admitted to the facility in 10/2022 with diagnoses including heart disease, depression, and urinary incontinence. The resident's service plan, dated 06/05/24, interim service plans, dated 05/10/24 through 09/18/24, and progress notes, dated 06/24/24 through 09/23/24, were reviewed and staff were interviewed. The service plan was not reflective of Resident 2's current care needs and/or did not provide clear direction to staff in the following areas: * Continent status and ability to use the restroom; * Instruction to staff relating to siderails and a transfer pole; * Behavior interventions including interventions for refusing medications; * Transfer assistance and how many staff were needed or may be needed; * Mobility equipment used; * How staff assist the resident with his/her leisure activities; * Housekeeping preferences; * Frequency of safety checks; * Pillow placement relating to non-drug interventions for pain; and * Directions for staff to change and/or empty a colostomy bag. Additionally, the resident’s most current service plan was not available to staff. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 27 (Area Director of Nursing) on 09/27/24 at 12:17 pm. They acknowledged the findings. 5. Resident 4 was admitted to the facility in 07/2022 with diagnoses including type 2 diabetes mellitus, chronic obstructive pulmonary disease, chronic pancreatitis, and chronic respiratory failure. The resident's current service plan available to staff, dated 06/17/24, interim service plans, dated 06/13/24 through 09/21/24, progress notes, dated 06/10/24 through 09/09/24, physician orders, and emergency department discharge summaries were reviewed, observations were made, and interviews were conducted. The following was identified: The service plan was not reflective of the resident's needs and preferences and/or did not provide clear instruction to staff in the following areas: * Resident specific symptoms of hyperglycemia and hypoglycemia and when to alert the MT; * Pain management including non-pharmaceutical interventions and PRN pain medication; * Nebulizer treatments and assistance level needed; * Medication management including which medications s/he self-administered and where the resident kept the medications; * Sleep routine and preferences of where to sleep; * Fall interventions; * Use of a hospital bed and to ensure it was in the lowest position; * Independent with toileting; * What staff should monitor and report relating to the resident’s skin; and * Housekeeping including clear instruction to staff regarding Resident 4’s personal unit and where s/he spends the majority of his/her time. The need to ensure the service plan reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (ED) and Staff 27 (Area Director of Nursing) on 09/27/24 at 11:23 am. They acknowledged the findings.

1)All residents for survey sample will be reviewed and updated to ensure they are reflective of residents current needs, provide clear direction to provide delivery of service, and be readily available to staff. 2)They system will be corrected by continual updates, schedule for care plan reviews done daily (business days) at clinical meeting. 3)Frequency of correction daily. 4)Executive Director

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

OAR 411-054-0036 (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 resident's choice, the facility administrator or designee, and at least one other staff person who provided services, for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5, and 6) whose service plans were reviewed. Findings include, but are not limited to: The current service plans for Residents 1, 2, 3, 4, 5, and 6 lacked documented evidence they had been developed by a service planning team. On 09/27/24 at 10:15 am, the need to ensure service plans were developed by a service planning team was discussed with Staff 1 (ED) and Staff 27 (Area Director of Nursing). They acknowledged the findings.

1)Residents from survey sample: In process of updating and holding care conference. 3 of 6 completed. Service planning team consists of Executive Director or designee, the resident, and resident legal representative if applicable, any person resident chooses, and at least one other staff who provides services. 2)System correction update upon completion of each evaluation, resident/family/and care plan team invite sent to accommodate all parites convenience. Documentation recorded of meeting attendees. 3)At move in and every daily clinical meeting. 4)Executive Director

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:

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 evaluate changes of condition, refer to the facility nurse when the change of condition was significant, determine and document actions or interventions, communicate the actions or interventions to staff on each shift, and monitor each resident consistent with his or her evaluated needs until resolution, for 3 of 6 sampled residents (#s 3, 4, and 6) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 10/2023 with diagnoses including unspecified diastolic (congestive) heart failure and had a history of reoccurring urinary tract infections (UTIs). The resident’s progress notes, dated 06/23/24 through 09/19/24, and interim service plans (ISPs) dated 06/11/24 through 09/23/24, were reviewed and staff were interviewed. The following changes of conditions were identified: On 07/29/24 Resident 6 returned from hospital with diagnoses of sepsis with a UTI, encephalopathy, and chronic pain. In an ISP dated 07/29/24, staff were directed to monitor for any side effects of the antibiotic the resident was taking, cognition changes, blood in urine, and pain with urinating. Staff were also directed to offer fluids, check on the resident three times per shift, and provide good personal hygiene after toileting assistance. Staff were directed to monitor and provide the above listed interventions for 72 hours. On 08/17/24, the resident reported having "respiratory issues" and stated, "I just don't feel well." An ISP dated 08/17/24 directed staff to collect a urine analysis (UA) on 08/18/24 during the evening or on the morning of 08/19/24. On 08/21/24, the facility received confirmation the resident had a UTI and contacted the pharmacy for an antibiotic. Later that day, staff called 911 and Resident 6 was taken back to the hospital. When the resident returned to the facility on 08/22/24, an ISP was implemented with the same directions to staff as what was on the previous ISP dated 07/29/24. This was also in place for72 hours. On 09/02/24, staff documented in a progress note that the resident was showing signs and symptoms of another UTI. On 09/07/24, an ISP was created with the same instructions for staff as the two previous ISPs, with the same time frame of 72 hours. In an interview with Staff 1 (ED) and Staff 3 (RCC) on 09/25/24 at 1:21 pm, they confirmed that Resident 6’s urine had not been analyzed after each course of antibiotics were finished to ensure the UTIs were resolved. The need to monitor each resident consistent with his or her evaluated needs until resolution was discussed with Staff 1 and Staff 3 on 09/25/24 at 1:21 pm. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 10/2022 with diagnoses including, type 2 diabetes and chronic obstructive pulmonary disorder. During the acuity interview on 09/23/24, the resident was identified for weight loss. The resident's current service plan, dated 07/09/24, progress notes dated 06/23/24 through 09/19/24, and interim service plans (ISPs) were reviewed. Staff were interviewed and observations of the resident were made. Staff documented the following in the resident's progress notes: * 07/09/24 - "Resident has recently had 5% weight loss.” Staff continued to document, “I have notified [his/her] PCP and placed [him/her] on alert charting with an ISP to review preferences and encourage snacks and for dietary to offer increased calories, extra sauces and gravies and whole fat dairy foods.” An interview with Staff 11 (Executive Chef) on 09/24/24 at 1:20 pm revealed the interventions in place for Resident 3’s weight loss had not been communicated to dining services. Staff 11 stated their system was to receive a “diet modification” form informing them of any dietary interventions needed and she confirmed one had not been received regarding Resident 3. There was no documented evidence the facility communicated the determined action or intervention to dietary staff. On 09/27/24 at 10:05 am, the need to ensure the facility communicated the determined action or intervention to staff on each shift was discussed with Staff 1 (ED) and Staff 27 (Area Director of Nursing). They acknowledged the findings. 3. Resident 4 was admitted to the facility in 07/2022 with diagnoses including type 2 diabetes mellitus, chronic obstructive pulmonary disease, chronic pancreatitis, and chronic respiratory failure. The resident's current service plan, dated 06/17/24, interim service plans, dated 06/13/24 through 09/21/24, progress notes dated 06/24/24 through 09/23/24, and after visit summaries were viewed, observations were made, and interviews were conducted. The following was identified: There was no documented evidence resident-specific actions or interventions were determined for short-term changes of condition, the actions or interventions were communicated on all shifts, and/or changes were monitored through resolution, with progress noted at least weekly, for the following: * 06/13/24: New medication – cephalexin (for infection); * 06/18/24: Discontinued medication – oxycodone (for pain); * 07/12/24: Allergic reaction to cortisone injection; * 07/15/24: New diagnosis’ of osteoarthritis and arthropathy; * 07/15/24: New medication – tramadol 50mg (for pain); * 07/19/24: New medication – hydrocodone 5-325mg (for pain); * 07/19/24: New diagnosis’ of knee effusion; * 07/19/24: New diagnosis’ of knee pain and ambulatory dysfunction; * 07/20/24: New diagnosis’ of acute knee pain; * 07/28/24: New diagnosis’ of flank pain; * 07/31/24: Fall off motorized wheelchair resulting in skin tears; * 08/19/24: Resident reported hypoglycemic episode at grocery store; * 08/27/24: New diagnosis of chest pain and hyperglycemia; * 08/28/24: New medication – Jardiance (for lowering blood sugar); * 09/06/24: Insulin change; * 09/07/24: New skin tear; * 09/09/24: Gastrointestinal illness; * 09/18/24: Insulin change; * 09/19/24: Vaginal bleeding; and * 09/21/24: New diagnosis’ of hematuria and constipation. On 09/25/24 at 1:06 pm, each identified change of condition was reviewed with Staff 27 (Area Director of Nursing). She acknowledged each change of condition and no additional information was provided. The need to ensure actions or interventions for short-term changes of condition were documented and communicated to staff on each shift, and the changes of condition were monitored weekly through resolution was discussed with Staff 1 (ED) and Staff 27 on 09/27/24 at 11:23 am. They acknowledged the findings.

1)Register Nurse (RN) completed a significant change audit and documented all changes to include the care plan of all resident's identified in survey. Survey Sample Residents 3, 4, & 6 2)Community RN will assess and monitor all short term and long term change of condition and document changes through resolution. 3)Short term and long term change of condition will be initiated within 24 hour requirement and RN to complete and document within 48-hours to reference back to care plan team the expectations. Reviews will occur daily at clinical meetings. 4)Executive Director & Nursing

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

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure a timely RN assessment was completed following significant changes of condition, including findings, resident status, and interventions made as a result for 4 of 4 sampled residents (#s 2, 3, 5, and 6) who experienced significant changes of condition. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 02/2022, with diagnoses including hyperlipidemia and chronic pain. Progress notes, dated 06/23/24 through 09/23/24, indicated the resident experienced the following significant change of condition: Resident 5 returned to the facility on 09/03/24, following a 13-day hospital admission. The resident had a diagnoses of sacrum fracture, sustained in an earlier fall in the community. Resident 5 was described as experiencing “decreased range of motion, limited mobility, and increased ADL needs”. Clinical records showed an RN assessment was conducted on 09/12/24, nine days after Resident 5 returned from the hospital. On 09/27/24, the need to ensure RN assessments were conducted and documented timely, following significant changes of condition was discussed with Staff 1 (ED) and Staff 27 (Area Director of Nursing). They acknowledged the findings. 2. Resident 3 was admitted to the facility in 10/2022 with diagnoses including, type II diabetes mellitus and chronic obstructive pulmonary disease. During the acuity interview on 09/23/24, the resident was identified for weight loss. The resident's current service plan, dated 07/09/24, progress notes dated 06/23/24 through 09/19/24, weights and vitals summary, dated 03/12/24 through 09/23/24, and interim service plans were reviewed. Weight records reviewed revealed the following: *03/12/24 – 146.6 pounds *06/26/24 – 135.4 pounds Between March and June of 2024, Resident 3 lost 11.2 pounds or 7.64% body weight in three months resulting in a severe weight loss. Staff documented the following in the resident's progress notes: * 07/02/24 - "PCP was faxed on 06/27/24 informing them of residents weight loss. PCP responded on 07/02/24 with, “Reviewed. Please send weights in 2 weeks.” * 07/09/24 – “Change of Condition” assessment was noted. “Resident has recently had 5% weight loss.” An interview with Staff 1 (ED) on 09/27/24 at 10:05 am revealed the facility was without an RN and had consultants that filled in which prevented the change of condition assessment from occurring timely. There was no documented evidence the facility completed a timely assessment for the significant change of condition related to weight loss, documented the resident status, and interventions made as a result of the assessment. On 09/27/24 at 10:05 am, the need to ensure the facility RN completed a timely assessment for the significant change of condition was discussed with Staff 1 and Staff 27 (Area Director of Nursing). They acknowledged the findings. 3. Resident 6 was admitted to the facility in 10/2023 with diagnoses including unspecified diastolic (congestive) heart failure. The resident’s weight records, dated 03/12/24 through 09/25/24, progress notes dated 06/23/24 through 09/19/24, and interim service plans, dated 06/11/24 through 09/23/24, were reviewed and staff were interviewed. The following was identified: Resident 6 had a physician’s order to be weighed daily. On 03/19/24, the resident’s weight was documented as 124 pounds. On 09/21/24, the resident’s weight was documented as 140 pounds. From 03/2024 to 09/2024, the resident had a weight gain of 16 pounds or 12.9 % of his/her body weight, which represented a significant change of condition. On 09/24/24 Staff 27 (Area Director of Nursing) confirmed there was no documented evidence of an RN assessment of Resident 6's significant change in condition which included findings, resident status, and interventions made as a result of the assessment to address the weight gain. The need to ensure the facility RN completed an assessment for the significant change in condition was discussed with Staff 1 (ED) and Staff 3 (RCC) on 09/25/24 at 1:21 pm. They acknowledged the findings. 4. Resident 2 was admitted to the facility in 10/2022 with diagnoses including heart osteoarthritis and depression. The resident’s facility record including interim service plans (ISPs), dated 05/10/24 through 09/18/24, were reviewed and staff were interviewed. An ISP dated 05/10/24 identified Resident 2 had returned from the hospital with a “broken wrist”. There were directions to staff to “check on the resident three times per shift to offer assistance” and to place Resident 2 on “alert charting for 72 hours”. During an interview with Staff 21 (CG) on 09/26/24 at 10:34 am, she reported that the resident had a significant decline with the fracture and continued to need increased ADL assistance as “[Resident 2] is really scared of falling again.” There was no documented evidence the RN completed an assessment of the resident's condition which included findings, resident status and interventions made as a result of the assessment to address the resident’s wrist fracture. The need to ensure the facility RN completed an assessment for the significant change in condition was discussed with Staff 1 (ED) and Staff 27 (Area Director of Nursing) on 09/27/24 at 12:17 pm. They acknowledged the findings.

1)Registered Nurse completed a significant change audit and documented all changes to include the care plan of all resident's identified in survey. Survey Samp[le resideents 2,3,5, & 6. Consultants have helped identify changes and made reccomendations to make the changes. 2)System correction will be done by community RN to complete the Role of the RN in CBC course. Weights will be monitored monthly and referred to the RN for significant change assessments. Medication tech training related to change of condition and notification to RN. 3)Daily at clinical meetings and ongoing. 4)Executive Director & Nursing

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by:

OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching (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:(B) Delegation and Teaching. Delegation and teaching must be provided and documented by a RN in accordance with the Oregon Administrative Rules adopted by the Oregon State Board of Nursing in chapter 851, division 047. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (# 4), who received insulin injections by unlicensed facility staff. Findings include, but are not limited to: According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the nursing procedure and observing the staff demonstrate the task. Resident 4 was admitted to facility in 07/2022 with diagnoses including diabetes. During the acuity interview on 09/23/24, the resident was identified to be administered insulin injections by unlicensed staff. Resident 4's MARs, dated 08/01/24 through 09/23/24, revealed insulin had been given by Staff 19 (MT) on multiple occasions. * Review of delegation documentation on 09/25/24 revealed there was no documented delegation completed for Staff 19. Staff 19 was to be instructed not to administer insulin to Resident 4 until delegation was completed The need to ensure staff who administered insulin injections were delegated in accordance with OSBN Division 47 Rules was discussed with Staff 6 (RN), on 09/25/24. She acknowledged the findings.

1)The medication tech who gave the insulin was immediately removed from the med tech position. She is no longer employed. 2)Delegating RN will ensure all delegations updated and training is provided. No undelegated/trained staff will administer any diabetic care requiring delgating. Delegation expiration sheet posted in med rooms. 2)In service will be conducted with the med techs that if they are not a delegated staff, they cannot administer any delegated medications. 3)Weekly 4) Executive Director & Nursing

OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching (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:(B) Delegation and Teaching. Delegation and teaching must be provided and documented by a RN in accordance with the Oregon Administrative Rules adopted by the Oregon State Board of Nursing in chapter 851, division 047. This Rule is not met as evidenced by:

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to coordinate care with outside providers and ensure staff were informed of new interventions and the service plan was adjusted if necessary for 1 of 4 sampled residents (# 6) who received outside services. Findings include, but are not limited to: Resident 6 was admitted to the facility in 10/2023 with diagnoses including unspecified diastolic (congestive) heart failure, scoliosis, and a history of urinary tract infections. The resident's outside provider notes, dated 08/09/24 through 09/06/24, progress notes dated from 06/23/24 through 09/19/24, and interim service plans (ISPs), dated from 06/11/24 through 09/23/24, were reviewed and staff were interviewed. The following recommendations were identified: * 08/05/24: Resident 6’s physician faxed the facility with direction to, “Try to drink at least [eight] glasses of water a day”; * 08/07/24: “Use gait belt [with] transfer and ambulation using walker”; * 08/09/24: “[Continue] to assist [the resident] with all mobility try to [continue] to use walker for transfers”; * 08/19/24: “Staff continue to try walk [to the] bathroom with walker and gait belt”; * 08/23/24: “Staff when able try walk to bathroom if you have time, use gait belt”; * 08/26/24: “Continue [with] staff trying [to stand and] transfer [with] walker”; * 08/28/24: “Use gait belt [for] all transfers allow [Resident 6] to process verbal cues to be able to participate better [with] functional tasks”; and * 09/19/24: The resident’s physician faxed the facility with direction to “wants us specifically monitoring for chest pain.” There was no documented evidence the following recommendations were communicated to staff: * Encouraging the resident to drink at least eight glasses of water a day; * The use of a gait belt and walker for all ambulation; * The use of a walker for all transfers; * Staff to assist Resident 6 with all mobility; and * Specific directions for staff to monitor for chest pain. There was no additional documented evidence caregiving staff were informed of the other above recommendations to ensure the continuity of care. The need to ensure the facility staff were informed of new interventions, and the service plan was adjusted if necessary was discussed with Staff 1 (ED) and Staff 3 (RCC) on 09/25/24 at 1:21 pm. They acknowledged the findings.

1)Process immediately updated for medication tech to write in the progress notes all visits and route a copy to clinical team. Clinical team will triage and assign appropriate follow up and make notifications based on provider comments. 2)Monitored through a triple check system. 3)Daily at clinical meeting 4)Executive Director & Nursing

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments (1) MEDICATION AND TREATMENT ADMINISTRATION SYSTEMS. The facility must have safe medication and treatment administration systems in place that are approved by a pharmacist consultant, registered nurse, or physician.(a) The administrator is responsible for ensuring adequate professional oversight of the medication and treatment administration system. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight of the medication and treatment administration systems. Findings include, but are not limited to: Administrative oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas: C 282: Delegation; C 302: Systems: Tracking Controlled Substances; C 303: Systems: Medication and Treatment Orders; C 305: Systems: Resident Right to Refuse; C 310: Systems: Medication Administration; C 325: Systems: Self Administration of Medication; and C 330: Systems: Psychotropic Medication On 09/27/24 at 10:15 am, the unsafe medication system and lack of adequate professional oversight was discussed with Staff 1 (ED) and Staff 27 (Area Director of Nursing). They acknowledged the findings.

Refer to POC and refer to violation C282, C302, C303, C305, C310, C325, and C330

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments (1) MEDICATION AND TREATMENT ADMINISTRATION SYSTEMS. The facility must have safe medication and treatment administration systems in place that are approved by a pharmacist consultant, registered nurse, or physician.(a) The administrator is responsible for ensuring adequate professional oversight of the medication and treatment administration system. This Rule is not met as evidenced by:

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 ensure an accurate system for tracking controlled substances, for 2 of 3 sampled residents (#s 4 and 5) who were prescribed PRN narcotic pain medications. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 02/2022, with diagnoses including hyperlipidemia and chronic pain. Resident 5 was prescribed PRN oxycodone 5mg to treat severe pain. The Controlled Substance Disposition Record was reviewed, along with the resident's MAR, dated 08/01/24 through 09/23/23. The following discrepancies related to administration of controlled substances were identified: The Disposition Record indicated a dose of two oxycodone 5mg tablets was removed from locked storage and administered on 09/17/24. However, there was no documentation on Resident 5’s MAR that the medication was administered. On 09/27/24 at 10:15 am, the need to maintain an accurate system for tracking controlled substances was reviewed with Staff 1 (ED) and Staff 27 (Area Director of Nursing). They acknowledged the findings. 2. Resident 4 was admitted to the facility in 07/2022 with diagnoses including type 2 diabetes mellitus, chronic obstructive pulmonary disease, chronic pancreatitis, and chronic respiratory failure. The resident's 08/01/24 through 09/23/24 MARs and Controlled Substance Disposition Log were reviewed and the following was identified: Resident 4 had signed physician orders for hydrocodone/apap 5-325mg tablets to be administered every eight hours for pain as needed. The Controlled Substance Disposition Log documented the hydrocodone was administered on 30 occasions; however, the MAR was initialed as administered on 27 occasions. On 09/26/24 at 2:10 pm, inconsistencies between the MAR and Controlled Substance Disposition logs were reviewed with Staff 27 (Area Director of Nursing). She reviewed the documentation and acknowledged the discrepancies. The need to ensure the facility had a system for tracking controlled substances was discussed with Staff 1 (Executive Director) and Staff 27 on 09/27/24 at 11:23 am. They acknowledged the findings.

1)Immediate audit of the Medication Administration Record (MAR) and disposition substance record (Narcotic book) Implemented a daily missed med report review followed up with med techs. 2)Medicaton Tech meeting completed Oct, 3, with additional training on Missed medications, MAR documentation, 7-rights. RN leads bi-weekly med tech meetings. Missed med report review daily at clinical meetings with follow up. 3)daily and biweekly 4)Executive Director

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:

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed, and written signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications the facility was responsible for administering for 3 of 6 sampled residents (#s 4, 5 and 6) whose records were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 07/2022 with diagnoses including type 2 diabetes mellitus, chronic obstructive pulmonary disease, chronic pancreatitis, and chronic respiratory failure. The resident's 08/01/24 to 09/23/24 MARs and physician orders dated 08/07/24 were reviewed, and the following was identified: a. There were multiple blanks on the MAR for the following medications: * Famotidine 20mg (for indigestion); * Lamotrigine 25mg (for anxiety and depression); * Jardiance 10mg (for type two diabetes); and * Docusate sodium 250mg (for constipation). Additional blanks on the MAR were identified for the following: * Check blood sugar twice daily (for signs and symptoms of hypoglycemia); * Hyperglycemic protocol if CBG is higher than 400 * Monitor resident behaviors of anger outbursts; * Monitor resident for verbal outbursts and agitation; and * Watch resident take all medication. b. The MAR identified the following medications were not available on multiple occasions: * Amitriptyline 10mg (for nerve pain); * Atorvastatin 40mg (for hyperlipidemia); * Cyanocobalamin 1000mcg/ml (for vitamin B deficiency); * Famotidine 20mg (for indigestion); * Furosemide 40mg (for hypertension); * Polyethylene glycol powder 17 grams (for constipation); * Trazodone 50mg (for insomnia); * Albuterol sulfate 0.083% (for acute and chronic respiratory failure); * Creon 12-38-60K (for pancreatitis); * Lamotrigine 25mg (for anxiety and depression); * Lidocaine 5% patch (for chronic pain); * Ropinirole 3mg (for restless leg syndrome); * Check blood sugar twice daily (for signs and symptoms of hypoglycemia); and * Monthly vitals including weight. On 09/26/24 at 11:56 am, Staff 27 (Area Director of Nursing) stated she had reviewed Resident 4’s MAR and confirmed the MAR contained multiple blanks, that medication was not available on multiple occasions, and was aware the residents MAR was not reflective of current signed physician orders. c. The resident had a signed physician order for Lantus 100 units/3 ml (for type 2 diabetes mellitus) the MAR indicated the medication was to be administered at 8:00 am. On 09/27/24 at 9:27 am, Staff 27 confirmed the administration dates and times for the Lantus 100 units/3 ml (for type 2 diabetes mellitus), which indicated the insulin was administered over an hour late on the following occasions: * 08/16/24 at 9:17 am; * 08/18/24 at 9:23 am; * 08/19/24 at 10:19 am; * 09/02/24 at 9:30 am; * 09/03/24 at 12:07 pm; * 09/09/24 at 12:20 pm; * 09/15/24 at 9:57 am; * 09/15/24 at 12:22 pm; and * 09/22/24 at 11:55 am. The need to ensure orders were carried out as prescribed and written signed physician or other legally recognized practitioner orders were documented in the resident's record was reviewed with Staff 1 (ED) and Staff 27 on 09/27/24 at 11:23 am. They acknowledged the findings. 2. Resident 5 was admitted to the facility on 02/2022, with diagnoses including hyperlipidemia and chronic pain. Review of Resident 5’s MARs, dated 08/01/24 through 09/23/24, and physician orders, dated 08/01/24, identified the following inaccuracies: Resident 5 was prescribed the routine medication acetaminophen 325 mg, with instructions to “take 2 tablets (650 mg) by mouth 4 times daily”. There were five instances of unexplained “blanks” in the administration record on the MAR, for this medication. In an interview on 09/25/24, Staff 27 (Area Director of Nursing) stated there was no explanation or further documentation, regarding the reason for these omissions on the MAR. On 09/27/24, the need to ensure all medication orders were carried out as prescribed was discussed with Staff 1 (ED) and Staff 27. They acknowledged the findings. 3. Resident 6 was admitted to the facility in 10/2023 with diagnoses including unspecified diastolic (congestive) heart failure and had a history of reoccurring urinary tract infections (UTIs). Resident 6's 08/01/24 through 09/23/24 MARs and physician's orders were reviewed, and staff were interviewed. a. The following was either not administered or carried out per physician's orders: * Daily weights: Nine times; * Simvastatin (for antihyperlipidemics): Resident 6 was not administered one dose; and * Acetaminophen (for pain), administer two tablets every six hours, scheduled: Resident 6 was not administered two doses. b. There were blanks on the MARs without indication if the physician’s orders were carried out as prescribed for the following: * Daily weights: Nine times; * Calcium (for regulating calcium levels): Once; * Ciprofloxacin (for UTI), administer one tablet every 12 hours for seven days: Twice; * Magnesium (for supplement): Twice; * Simvastatin: Once; and * Gabapentin (for nerve pain): Once. The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (ED) and Staff 3 (RCC) on 09/25/24 at 1:21 pm. They acknowledged the findings. 4. Resident 2 was admitted to the facility in 10/2022 with diagnoses including osteoarthritis and urinary incontinence. The resident's 08/01/24 through 09/23/24 MARs and physician's orders were reviewed, and staff were interviewed. a. Acetaminophen (for pain) was not administered eight times as the resident “was sleeping”. b. There were blanks on the MARs without indication if the physician’s orders were carried out as prescribed for the following days: * 08/18/24: Gabapentin (for osteoarthritis) and oxybutynin (for urinary incontinence); and * 08/19/24: Oxycodone (for pain) at 8:00 am and at 8:00 pm. c. Resident 2 had signed orders for staff to obtain vitals and a weight each month. On 08/05/24 staff noted, “unable to obtain”. There was not additional documentation. The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (ED) and Staff 27 (Area Director of Nursing) on 09/27/24 at 12:17 pm. They acknowledged the findings.

1)10/17/2024 Medication Tech meeting to put process into place for documenting missed medications and reordering. 2)Notify Pharmacy, follow up next day with phone call and document, 3rd follow up with phone call and if still not received, notify Physician. Monitoring during daily clinical meetings. 3)Daily 4)Executive Director

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

OAR 411-054-0055 (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 or other practitioner when a resident refused consent to orders for 1 of 2 sampled resident (#s 4 and 6), who had documented medication and treatment refusals. Findings include, but are not limited to: Resident 4 was admitted to the facility in 07/2022 with diagnoses including type 2 diabetes mellitus, chronic obstructive pulmonary disease, chronic pancreatitis, and chronic respiratory failure. The resident's 08/01/24 to 09/23/24 MARs and physician orders dated 08/07/24 were reviewed, and identified Resident 4 refused the following orders on multiple occasions: * Furosemide 40mg (for hypertension); * Lidocaine 5% patch (for chronic pain); * Polyethylene glycol powder 17 grams (for constipation);* Check blood sugar twice daily (for signs and symptoms of hypoglycemia);* Trelegy ellipta (for chronic obstructive pulmonary disease); and * Albuterol sulfate 0.083% (for acute and chronic respiratory failure). On 09/27/24, Staff 17 (MT) confirmed there was no documented evidence the practitioner was notified of the multiple refusals. The need to notify the physician or other practitioner when a resident refused consent to orders was discussed with Staff 1 (Executive Director) and Staff 27 (Area Director of Nursing) on 09/27/24. They acknowledged the findings.

1) Notify Physician for missed medication for Survey Sample Resident #4 1)At medication tech meeting disucussion surrounding the resident has the right to refuse medications and to notify Dr for first missed dose. 2)Notify Dr. for first missed dose by fax. and document Physicians response. Continue notifications until further instructions from PCP 3)Daily at clinical meetings 4)Executive Director

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:

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 an accurate MAR was kept for all medications that were ordered by a legally recognized prescriber and administered by the facility, for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5, and 6) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 02/2022 with diagnoses including hyperlipidemia and chronic pain. Review of the resident’s MARs, dated 08/01/24 through 09/23/24, identified the following inaccuracies: * Resident 5 was prescribed two different PRN medications for pain. These were oxycodone 5 mg and tizanidine 2 mg. The MAR lacked instructions regarding the sequential order of use for these medications; and * The instructions for use of PRN oxycodone were “take 1-2 tablets (5-10 mg) by mouth every 4 hours as needed for severe pain.” These instructions did not provide adequate direction for unlicensed staff to determine appropriate dosage for this medication. On 09/27/24, the need to ensure MARs were accurate and provided adequate instructions for unlicensed staff was discussed with Staff 1 (ED) and Staff 27 (Area Director of Nursing). They acknowledged the findings. 2. Resident 6 was admitted to the facility in 10/2023 with diagnoses including unspecified diastolic (congestive) heart failure. The resident's 08/01/24 through 09/23/24 MARs and Administration Notes for the same dates were reviewed, and staff were interviewed. The following inaccuracies were identified: * The MARs lacked direction to unlicensed staff relating to what to report and who to report to when obtaining daily weights; and * The key that MTs were documenting in the MARs, “9 = Other/See Progress Notes,” lacked specific information of why an order was not carried out as prescribed. Examples of the documentation were, “unable this shift,” “unable,” “unable to obtain,” “did not get,” or there was no documentation in the Administration Note. This pertained to weights, vital signs, and scheduled acetaminophen (for pain). The need to ensure MARs were accurate and included resident-specific instructions was discussed with Staff 1 (ED) and Staff 3 (RCC) on 09/25/24 at 1:21 pm. They acknowledged the findings. 3. Resident 1 was admitted to the facility in 08/2024 with diagnoses including pneumonia due to Coronavirus and type 2 diabetes mellitus. The resident’s MARs, dated 08/01/24 through 09/23/24, were reviewed and the following was noted: Resident 1 was prescribed bisacodyl, Milk of Magnesia, polyethylene glycol, Senna, and sodium phosphate enema for constipation. The MAR lacked instructions for staff as to order of use for these medications. On 09/26/24 at 12:52 pm, Staff 15 (MT) confirmed there were no directions to unlicensed staff instructing them on the order of administration of the PRN medications. The need to ensure accurate documentation of the MAR and to provide clear parameters when a resident was prescribed more than one PRN medication for the same condition was reviewed with Staff 1 (ED) and Staff 27 (Area Director of Nursing) on 09/27/24 at 10:05 am. The findings were acknowledged. 4. Resident 3 was admitted to the facility in 10/2022 with diagnoses including type 2 diabetes mellitus and chronic obstructive pulmonary disorder. The resident’s MARs, dated 08/01/24 through 09/23/24, were reviewed, and multiple medications lacked a reason for use. On 09/26/24 at 12:52 pm, the surveyor and Staff 15 (MT) reviewed the electronic MAR and confirmed no additional information was included on the electronic MAR versus the printed MAR. The need to ensure the facility maintained accurate MARs was discussed with Staff 1 (ED) and Staff 27 (Area Director of Nursing) on 09/27/24 at 10:05 am. The findings were acknowledged. 5. Resident 2 was admitted to the facility in 10/2022 with diagnoses including hypertension, heart disease, and osteoarthritis. The resident's 08/01/24 through 09/23/24 MARs, Administration Notes for the same dates, and progress notes, dated 06/24/24 through 09/23/24, were reviewed. Staff were interviewed, and the following inaccuracies were identified: a. Resident 2 had an order for scheduled acetaminophen (for pain). For the 6:00 am dose on both 08/13/24 and 08/22/24, staff documented either “5 = Hold/See Progress Notes” or “9 = Other/See Progress Notes.” There were no corresponding notes for the above dates or times. b. On 08/22/24, staff documented “21 = Withheld per PCP/LN orders” for the following medications: * Amlodipine (for hypertension); * Aspirin (for heart disease); * Oxycodone (for pain); * Gabapentin (for osteoarthritis); * Omeprazole (for gastro-esophageal reflux); and * Tramadol (for left shoulder pain). There was no documented evidence of communication with the resident’s physician or nurse relating to why the medications needed to be held. There was also no information on the signed orders relating to when staff should hold the above medications. c. Resident 2 had two PRN medications for pain, acetaminophen and Oxycodone. On 09/26/24 at 2:58 pm, Staff 18 (MT) confirmed there were no directions to unlicensed staff instructing them on the order in which to administer the PRN medications. The need to ensure MARs were accurate and included resident-specific instructions was discussed with Staff 1 (ED) and Staff 27 (Area Director of Nursing) on 09/27/24 at 12:17 pm. They acknowledged the findings. 6. Resident 4 was admitted to the facility in 07/2022 with diagnoses including type 2 diabetes mellitus, chronic obstructive pulmonary disease (COPD), chronic pancreatitis, and chronic respiratory failure. The resident's 08/01/24 to 09/23/24 MARs and physician orders dated 08/07/24 were reviewed, and the following was identified: a. Resident 4’s MARs noted the resident could self-administer the following medications: * Lidocaine 5% patch (for chronic pain); * Tretinoin 0.025% cream (for acne); * Albuterol hfa 90mcg inhale (for COPD); * Guaifenesin 400mg tablet (for cough/congestion); and * Nystatin 100,000u/g powder (for skin care/rash). The resident’s MAR also noted that staff, “Must witness all medication administrations. Medications are not to be in the resident’s room. Resident is not safe to self-administer medications.” b. The MAR lacked parameters for the following prn pain medications: * Hydrocodone 5-325mg: one to two tabs every four hours as needed for pain; * Hydrocodone 5-325mg: one tab by mouth every eight hours as needed for pain; * Tramadol 50mg: one tab by mouth every eight hours as needed for pain; and * Acetaminophen 325mg: two tablets by mouth every four hours as needed for mild pain. On 09/26/24 at 9:52 pm, Staff 17 (MT) confirmed the MARs did not identify in what order to administer prn pain medication. The need to ensure an accurate medication administration record was kept for all medications, including over-the-counter medications, administered by the facility was reviewed with Staff 1 (ED) and Staff 27 (Area Director of Nursing) on 09/27/24 at 11:23 am. They acknowledged the findings.

1)Pharmacy audit completed for Psychotropic medications and PRN's was completed 10/11/2024 to include Survey sample residents 1, 2, 3, 4, 5, 6. Registered Nurse to follow up on all recommendations. A complete MAR audit is scheduled with Consonus Pharmacy Nov. 6. 7. and 8. 2)RN to review all move in medication orders, any new medications prescribed, and quarterly audits with appropriate documentation and parameters. Also Pharmacy to complete quarterly audits. 3) Daily, weekly, monthly, quarterly 4)Executive Director & Nursing

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:

OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order. This Rule is not met as evidenced by: Based on observation, interview, and record review it was determined the facility failed to evaluate residents who self-administered over-the-counter medications to ensure the ability to safely administer the medications for 2 of 3 sampled residents (#s 4 and 6). Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 10/2023 with diagnoses including osteoarthritis and dementia. The resident's medical record and MARs, dated 08/01/24 through 09/23/24, were reviewed. Staff were interviewed and the following was identified: There were two PRN over-the-counter medications listed on Resident 6's MARs: Preparation H and Tucks medicated pads, both used for the treatment of hemorrhoids. During an interview with Staff 22 (CG) on 09/25/24 at 10:21 am, she identified that both of those medications were located in the resident's bathroom and that she assisted with the application of the medications while providing toileting assistance. Staff 22 also reported Resident 6 had Salonpas, a roll-on topical over-the-counter medication used to treat pain. In an interview on 09/25/24 at 1:21 pm, Staff 1 (ED) confirmed there was no evaluation to ensure the resident could safely self-administer the over-the-counter medications. The need to evaluate a resident's ability to safely self-administer over-the-counter medications was discussed with Staff 1 and Staff 3 (RCC) on 09/25/24 at 1:21 pm. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 07/2022 with diagnoses including type 2 diabetes mellitus, chronic obstructive pulmonary disease, chronic pancreatitis, and chronic respiratory failure. The resident's facility record and MARs dated 08/01/24 through 09/23/24 were reviewed, interviews were conducted, and observations were made. The following was identified: The resident’s MARs also stated that staff “[must] witness all medication administrations. Medications are not to be in the resident’s room. Resident is not safe to self-administer medications.” Resident’s 4 MARs listed the following medications: * Epinephrine 0.3mg injection (for anaphylaxis); * Lidocaine 5% patch (for pain); * Tretinoin 0.025% cream (for acne); * Albuterol sulf 0.083% nebulizer treatment (for chronic respiratory failure); * Albuterol hfa 90mcg inhale (for COPD); and * Guaifenesin 400mg tablet (for cough/congestion). On 09/24/24 at 10:54 am, Resident 4 stated facility staff regularly left the following medications in his/her room to self-administer: * Lidocaine 5% patch (for pain); * Tretinoin 0.025% cream (for acne); * Albuterol sulf 0.083% nebulizer treatment (for chronic respiratory failure); and * Albuterol hfa 90mcg inhale (for COPD). On 09/26/24 at 9:52 pm, Staff 17 (MT) confirmed Resident 4 self-administered the following medications: * Lidocaine 5% patch (for pain); * Tretinoin 0.025% cream (for acne); * Albuterol sulf 0.083% nebulizer treatment (for chronic respiratory failure); and * Nystatin 100,000u/g powder (for skin care/rash). On 09/26/24 at 10:31 am, Staff 27 (Area Director of Nursing) confirmed there was no evaluation to ensure the resident could safely self-administer the listed medication. The need to evaluate a resident's ability to safely self-administer medication was discussed with Staff 1 (ED) and Staff 27 on 09/27/24 at 11:23 am. They acknowledged the findings.

1)Self medication assessments have been initiated for survey sample residents 4 & 6. 2)Self med assessment to be completed for all residents who have expressed desire or been observed self medicating. 3)Quarterly or at change of condition 4)Executive Director

OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order. This Rule is not met as evidenced by:

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 ensure PRN medications used to treat a resident’s behaviors had written, resident-specific parameters and non-pharmacological interventions for staff to attempt prior to administering a PRN psychotropic medication for 1 of 1 sampled resident (# 6) who was prescribed a PRN psychotropic medication. Findings include, but are not limited to: Resident 6 was admitted to the facility in 10/2023 with diagnoses including anxiety. The resident's 08/01/24 through 09/23/24 MARs and physician's orders were reviewed, and staff were interviewed. Resident 6 had an order for alprazolam, 0.25 mgs, one tablet as needed for anxiety. The medication was administered 101 times. On 09/26/24 at 2:58 pm, Staff 18 (MT) confirmed there were no non-drug interventions listed for staff to attempt prior to administering the PRN psychotropic. There was no documented evidence non-pharmacological interventions had been tried with ineffective results prior to administering the medications. The need to ensure resident-specific, non-pharmacological interventions for staff to try prior to the administration of a PRN psychotropic, which included documentation of the interventions tried with ineffective results, was discussed with Staff 1 (ED) and Staff 27 (Area Director of Nursing) on 09/27/24 at 12:17 pm. They acknowledged the findings.

1)Pharmacy audit completed for Psychotropic medicaions and PRN's was completed 10/11/2024 to include Survey Sample resident #6. RN to follow up on all recommendations. Non medication interventions added to Medication Administration Records and careplan. 2)All new move ins will have non pharmacologial interventions put into place at time of move in, Quarterly Audits to ensure interventions put into place. All interventions to be documented before giving any PRN's in the progress notes. A3)t Move in, Quarterly at time of care plan reviews, Daily when running Medication reports at clinical meetings. 4)Executive Director & Nursing

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:

OAR 411-054-0037 (1a)(2-3) Acuity Based Staffing Tool - Elements (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING. Facilities must select and implement an acuity-based staffing tool (ABST) that is technology-based for determining appropriate staffing levels. Individual resident needs and care elements must be the primary consideration when developing and maintaining an ABST. Regardless of the ABST adopted, all requirements set forth in this rule and OAR 411-054-0034 (Resident Move in Evaluation) must be met. Facilities shall: (a) Select and implement the Department’s developed ABST or submit a proprietary ABST to the Department for approval as outlined in paragraph (2) of this rule. (2) PROPRIETARY ABST. A facility that chooses to use a proprietary ABST must implement a Department-approved ABST that meets this rule. (a) REQUIRED ELEMENTS. The proprietary ABST the facility adopts must meet the following requirements: (A) Address and document all individual ABST care elements outlined in paragraph (3) of this rule. (B) When calculating total time, the ABST must include the care elements for each resident and staff time needed to complete each individual care element. (C) Ensure the ABST can produce a report that identifies all residents currently residing in the facility, the care elements for each of the residents, and the staff time required to complete each care element for each resident. (D) Ensure the ABST can present the total time, in minutes, required to meet the scheduled needs for all residents, 24 hours a day, seven days a week, preferably per shift, per day. (E) Identify the date the resident’s ABST evaluation was last completed. (F) If applicable, determine ABST time for both residents on a Specific Needs Contract and residents not on a Specific Needs Contract to build posted staffing plans as outlined in this rule. (b) PROPRIETARY ABST REVIEW REQUEST. If a facility proposes to use a proprietary ABST, the facility must submit the ABST Proprietary Department Review Request (PDRR) Form, including but not limited to the following: (A) All facilities which currently have implemented a proprietary ABST must submit a PDRR Form no later than August 31, 2024. Facilities which do not submit a request on or before August 31, 2024, will be subject to corrective action as outlined in paragraph (9) of this rule. (B) Completed ABST PDRR Form. (C) Sample ABST report displaying all the ABST care elements listed in paragraph (3) of this rule, and the estimated staff time needed to complete each care element, shown per day, in minutes. Although not required, it is preferred that staff time be shown per shift, per day, in minutes. (D) The facility’s ABST policy required under OAR 411-054-0025(7)(i). (c) ABST SUMMARY STATEMENT. If the proprietary review request is approved, a facility must develop and maintain an ABST Summary Statement. The summary statement must be available upon request by the Department. An ABST summary statement must contain a general guide of how the ABST functions, as outlined on the PDRR form. (d) DEPARTMENT REVIEW OF PROPOSED PROPRIETARY ABST REQUEST. The Department will review and either approve or deny the facility’s proprietary ABST. The Department may request additional documentation, potentially including a virtual demonstration, to make the determination. If the ABST is deemed to not meet this rule, the Department may deny or rescind approval at any time. (e) APPEALS PROCESS. The Department will determine whether to approve or deny the request. If the proprietary ABST is denied or rescinded, the facility is entitled to a contested case hearing pursuant to ORS chapter 183. Prior to a contested case hearing, the facility may request an informal conference. (f) ANNUAL STATEMENT. Once approved, the facility must provide the Department an annual statement attesting no substantive changes have occurred to the design of the facility’s proprietary ABST that impacts its functionality. The facility must submit statements to the Department every year, between January 1 and March 31. (g) If the facility makes substantive changes to the design of its proprietary ABST that impacts the ABST’s functionality and if such changes would make the information submitted in support of its approval inaccurate or invalid, the facility must re-submit the ABST PDRR Form as described in this rule to the Department for review prior to implementing the new or revised ABST. (3) ABST CARE ELEMENTS. The required ABST care elements include activities of daily living and other tasks related to resident care and services, as outlined in OAR 411-054-0030, 411-054-0034, and 411-057- 0160. If any individual care element requires more than one staff, additional time must be accounted for as described in 411-054-0070(1). The ABST must individually address and document the care time required to complete each of the following individual ABST care elements: (a) Personal hygiene. (b) Grooming. (c) Dressing and undressing. (d) Toileting, bowel, and bladder management. (e) Bathing. (f) Transfers. (g) Repositioning. (h) Ambulation. (i) Supervising, cueing, or supporting while eating. (j) Medication administration. (k) Providing non-drug interventions for pain management. (l) Providing treatments. (m) Cueing or redirecting due to cognitive impairment or dementia. (n) Ensuring non-drug interventions for behaviors. (o) Assisting with leisure activities, assist with social and recreational activities. (p) Monitoring physical conditions or symptoms. (q) Monitoring behavioral conditions or symptoms. (r) Assisting with communication, assistive devices for hearing, vision, and speech. (s) Responding to call lights. (t) Safety checks, fall prevention (u) Completing resident specific housekeeping or laundry services performed by care staff. (v) Providing additional care services. If additional services are not provided, this element can be omitted. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to maintain an updated staffing plan, complete an Acuity-Based Staffing Tool (ABST) assessment for each resident, review each resident’s ABST assessment no less than quarterly, and ensure each ABST assessment accurately reflected the number of weekly minutes required to meet the needs of residents. Findings include, but are not limited to: The facility was unable to maintain an updated staffing plan because of the following issues with the facility’s ABST: a. The facility used the Department-developed ABST. The data contained in the tool was reviewed on 09/23/24 and it was determined seven unsampled residents had not been assessed and the time required to address their ADLs and other care tasks had not been entered into the facility ABST. In an interview on 09/24/24 at 11:15 am, Staff 1 (ED) acknowledged not all residents’ care needs had been assessed and entered into the ABST. b. The data in the ABST was reviewed and it was determined nine residents’ ABST assessments had not been documented as having been reviewed at least quarterly. Four residents’ assessments had been last reviewed in 05/2024 or 06/2024 and the other five residents’ assessments had been last reviewed in 12/2023. c. Multiple unsampled residents expressed concerns in the group interview on 09/24/24 and individually to the survey team that there was often a long wait for staff to respond when they pushed their call button for assistance. The facility provided the survey team with the call light response report (“Tek-Care Report”) from 09/11/24 through 09/25/24. Seven residents were noted to have used their call button more than 100 times during this period. Review of each of the seven residents’ individual ABST assessments indicated the number of times staff responded to call lights each week that the facility entered into the ABST was lower that the number of times the call light response report documented the resident actually used their call button. d. Six sampled residents’ ABST assessments were reviewed. The assessments for 4 of 6 of the sampled residents (#s 1, 2, 4, and 6) were not accurate as to the time or frequency required to complete the following individual care elements: * Transfers; * Providing treatments; * Ensuring non-drug interventions for behaviors; * Monitoring physical conditions or symptoms. * Safety checks/fall prevention; and * Completing resident-specific housekeeping services. Deficiencies related to the facility’s application of the ABST was reviewed with Staff 1 (ED) and Staff 27 (Area Director of Nursing) on 09/27/24. They acknowledged the findings.

1)Residents from survey sample ABST has been updated with accurate accounting and been compared to careplan. 2)ABST will be implemented prior to move in, updated at every care conference and at any change of conditions. 3)At move in, quarterly, and for any condition changes 4)Executive Director

OAR 411-054-0037 (1a)(2-3) Acuity Based Staffing Tool - Elements (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING. Facilities must select and implement an acuity-based staffing tool (ABST) that is technology-based for determining appropriate staffing levels. Individual resident needs and care elements must be the primary consideration when developing and maintaining an ABST. Regardless of the ABST adopted, all requirements set forth in this rule and OAR 411-054-0034 (Resident Move in Evaluation) must be met. Facilities shall: (a) Select and implement the Department’s developed ABST or submit a proprietary ABST to the Department for approval as outlined in paragraph (2) of this rule. (2) PROPRIETARY ABST. A facility that chooses to use a proprietary ABST must implement a Department-approved ABST that meets this rule. (a) REQUIRED ELEMENTS. The proprietary ABST the facility adopts must meet the following requirements: (A) Address and document all individual ABST care elements outlined in paragraph (3) of this rule. (B) When calculating total time, the ABST must include the care elements for each resident and staff time needed to complete each individual care element. (C) Ensure the ABST can produce a report that identifies all residents currently residing in the facility, the care elements for each of the residents, and the staff time required to complete each care element for each resident. (D) Ensure the ABST can present the total time, in minutes, required to meet the scheduled needs for all residents, 24 hours a day, seven days a week, preferably per shift, per day. (E) Identify the date the resident’s ABST evaluation was last completed. (F) If applicable, determine ABST time for both residents on a Specific Needs Contract and residents not on a Specific Needs Contract to build posted staffing plans as outlined in this rule. (b) PROPRIETARY ABST REVIEW REQUEST. If a facility proposes to use a proprietary ABST, the facility must submit the ABST Proprietary Department Review Request (PDRR) Form, including but not limited to the following: (A) All facilities which currently have implemented a proprietary ABST must submit a PDRR Form no later than August 31, 2024. Facilities which do not submit a request on or before August 31, 2024, will be subject to corrective action as outlined in paragraph (9) of this rule. (B) Completed ABST PDRR Form. (C) Sample ABST report displaying all the ABST care elements listed in paragraph (3) of this rule, and the estimated staff time needed to complete each care element, shown per day, in minutes. Although not required, it is preferred that staff time be shown per shift, per day, in minutes. (D) The facility’s ABST policy required under OAR 411-054-0025(7)(i). (c) ABST SUMMARY STATEMENT. If the proprietary review request is approved, a facility must develop and maintain an ABST Summary Statement. The summary statement must be available upon request by the Department. An ABST summary statement must contain a general guide of how the ABST functions, as outlined on the PDRR form. (d) DEPARTMENT REVIEW OF PROPOSED PROPRIETARY ABST REQUEST. The Department will review and either approve or deny the facility’s proprietary ABST. The Department may request additional documentation, potentially including a virtual demonstration, to make the determination. If the ABST is deemed to not meet this rule, the Department may deny or rescind approval at any time. (e) APPEALS PROCESS. The Department will determine whether to approve or deny the request. If the proprietary ABST is denied or rescinded, the facility is entitled to a contested case hearing pursuant to ORS chapter 183. Prior to a contested case hearing, the facility may request an informal conference. (f) ANNUAL STATEMENT. Once approved, the facility must provide the Department an annual statement attesting no substantive changes have occurred to the design of the facility’s proprietary ABST that impacts its functionality. The facility must submit statements to the Department every year, between January 1 and March 31. (g) If the facility makes substantive changes to the design of its proprietary ABST that impacts the ABST’s functionality and if such changes would make the information submitted in support of its approval inaccurate or invalid, the facility must re-submit the ABST PDRR Form as described in this rule to the Department for review prior to implementing the new or revised ABST. (3) ABST CARE ELEMENTS. The required ABST care elements include activities of daily living and other tasks related to resident care and services, as outlined in OAR 411-054-0030, 411-054-0034, and 411-057- 0160. If any individual care element requires more than one staff, additional time must be accounted for as described in 411-054-0070(1). The ABST must individually address and document the care time required to complete each of the following individual ABST care elements: (a) Personal hygiene. (b) Grooming. (c) Dressing and undressing. (d) Toileting, bowel, and bladder management. (e) Bathing. (f) Transfers. (g) Repositioning. (h) Ambulation. (i) Supervising, cueing, or supporting while eating. (j) Medication administration. (k) Providing non-drug interventions for pain management. (l) Providing treatments. (m) Cueing or redirecting due to cognitive impairment or dementia. (n) Ensuring non-drug interventions for behaviors. (o) Assisting with leisure activities, assist with social and recreational activities. (p) Monitoring physical conditions or symptoms. (q) Monitoring behavioral conditions or symptoms. (r) Assisting with communication, assistive devices for hearing, vision, and speech. (s) Responding to call lights. (t) Safety checks, fall prevention (u) Completing resident specific housekeeping or laundry services performed by care staff. (v) Providing additional care services. If additional services are not provided, this element can be omitted. This Rule is not met as evidenced by:

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure all pre-service orientation was completed and documented for 3 of 3 newly hired staff (#s 19, 23, and 24). Findings include, but are not limited to: On 09/24/24 at 2:40 pm, training records were reviewed with Staff 14 (Business Office Manager). The following deficiencies were identified: a. Staff 19 (MT) was hired on 08/01/24 and had not completed pre-service training in the following areas prior to performing any job duties: * Pre-service dementia training. b. Staff 23 (CG) was hired on 08/06/24 and had not completed pre-service training in the following areas prior to performing any job duties: * Resident rights and values of CBC care; * Abuse reporting requirements; and * Fire safety and emergency procedures. c. Staff 24 (CG) was hired on 08/13/24 and had not completed pre-service training in the following areas prior to performing any job duties: * Resident rights and values of CBC care; * Abuse reporting requirements; * Fire safety and emergency procedures; * Infectious Disease Prevention training; and * Approved HCBS course. The need to ensure all newly hired staff completed pre-service orientation training prior to providing care to residents was discussed with Staff 14 on 09/24/24 at 2:40 pm and Staff 1 (ED) and Staff 27 (Area Director of Nursing) on 09/27/24 at 10:05 am. They acknowledged the findings.

1) Staff from survey sample 19, 23, 24 to complete all pre-service training including: infectious disease prevention, Abuser reporting, resident rights, fir life and safety, infectious prevention, home and community based care course, and abdominal thrust. 2)All staff to complete all training required within 30 days of hire including: role of service plans, providing assistance with activities of daily living, changes associated with normal aging, identification, documentation and reporting of changes of condition, conditions that require assessment, treatment, observation and reporting, 2)System will be in place to track annual in-service training including annual infectious disease and six hours of dementia care trainig. 2) Development of a training tracking system to include all current and any future employees. The tracking system will contain all required training and completion dates, staff names, and hire dates. 3) Once implemented the system will be audited weekly and then monthly once compliance is maintained. 4)Executive Director

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by:

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. 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 newly hired direct care staff (#s 19, 23, and 24) demonstrated competency in all required areas within 30 days of hire. Findings include, but are not limited to: Review of the facility's training records on 09/24/24 at 2:40 pm with Staff 14 (Business Office Manager) revealed the following: a. Staff 19 (MT) was hired 08/01/24, and there was no documented evidence of competency demonstrated in the following areas: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * General food safety, serving and sanitation; and * First Aid/Abdominal Thrust. b. Staff 23 (CG) was hired 08/06/24, and there was no documented evidence of competency demonstrated in the following areas: * Role of service plans in providing individualized care; * Changes associated with normal aging; * General food safety, serving and sanitation; and * First Aid/Abdominal Thrust. c. Staff 24 (MT) was hired 08/13/24, and there was no documented evidence of competency demonstrated in the following areas: * Role of Service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; and * First Aid/Abdominal Thrust. The need to ensure all newly hired staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 14 on 09/24/24 at 2:40 pm and Staff 1 (ED) and Staff 27 (Area Director of Nursing) on 09/27/24 at 10:05 am. They acknowledged the findings.

1)Staff from Survey sample 19, 23, and 24 will have documented competencies in place for role of the service planning. 2)Business office manager will manage the competency check list of all new hires within 30-days of hire. The competency checklist will be kept in the employee file. 3)At time of hire and every 30-days. 4)Executive Director

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by:

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 1 of 1 long-term direct care staff (#20) 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 with Staff 14 (Business Office Manager) on 09/24/24 at 2:40 pm revealed the following: There was no documented evidence Staff 20 (CG), hired 03/28/22, had completed 12 hours of annual in-service training related to the provision of care in CBC, including six hours of training related to dementia care. 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 six hours related to dementia care topics, was discussed with Staff 14 on 09/24/24 at 2:40 pm and with Staff 1 (ED) and Staff 27 (Area Director of Nursing) on 09/27/24 at 10:05 am. They acknowledged the findings.

1)Survey sample 14, employee will be assigned 12-hours inservice training to complete annual training requirements to include the provision of care in CBC and six hour dementia training. 2)All employees to be assigned training to include: preservice training, annual training and biennial inservice. Tracking system to be put in place to track all training for current and future staff. 3)Once system is in place monthly auditing until complaince is met and maintained. 4)Executive Director

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:

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory care communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were maintained in good repair. Findings include, but are not limited to: The exterior of the facility was toured on 09/23/24 at 2:05 pm, and the following was identified: Exterior sidewalks around the facility had multiple drop-offs up to four inches, measured from the concrete to the ground. These drop-offs created potential hazards for residents. On 09/24/24 at 2:30 pm, the building's exterior was toured with Staff 8 (Environmental Services Director). He acknowledged the findings.

1)10/10/2024 Pacific Landscaping laid new barkdust, added new soil and seeded the new soil. 2)Maintenance Director will walk grounds every week when landscapers visit and maintenance to grounds will be completed on that day. 3)Weekly 4)Executive Director

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory care communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by:

OAR 411-054-0300 (4)(a-b) General Building Interior (4) GENERAL BUILDING INTERIOR. The design of an ALF must emphasize a residential appearance while retaining the features required to support special resident needs as outlined in this rule.(a) RECEPTION AREA. A reception area must be visible and accessible to residents and visitors when entering the doors of the main entrance to the ALF.(b) CORRIDORS. Resident-use areas and units must be connected through temperature controlled common corridors.(A) Resident-use corridors exceeding 20 feet in length to an exit or common-use area, must have a minimum width of 72 inches.(B) Corridors shall not exceed 150 feet in length from any resident unit to a seating or other common-use area.(C) Handrails must be installed at one or both sides of resident-use corridors. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure handrails were installed at one or both sides of resident-use corridors. Findings include, but are not limited to: The interior of the building was toured on 09/23/24 at 2:05 pm and the following was identified on the first floor. * There was an approximately 10-foot corridor which lacked a handrail on either side, where the residents’ mailboxes were located; and * There was an approximately 20-foot corridor which lacked a handrail on either side between Staff 1’s (ED) office window and the door leading into a stairwell. The need to ensure handrails were accessible to residents along corridors was discussed with Staff 8 (Environmental Services Director) on 09/24/24 at 2:30 pm. He acknowledged the findings.

1)Quote obtained on 10/14/2024 to install handrails, work will be will be scheduled as soon as all supplies are obtained and the company can get out. 2)Handrails are permenant and will be inspected weekly during routine housekeeping to keep them clean and free of splinters. 3)Weekly 4)Executive Director

OAR 411-054-0300 (4)(a-b) General Building Interior (4) GENERAL BUILDING INTERIOR. The design of an ALF must emphasize a residential appearance while retaining the features required to support special resident needs as outlined in this rule.(a) RECEPTION AREA. A reception area must be visible and accessible to residents and visitors when entering the doors of the main entrance to the ALF.(b) CORRIDORS. Resident-use areas and units must be connected through temperature controlled common corridors.(A) Resident-use corridors exceeding 20 feet in length to an exit or common-use area, must have a minimum width of 72 inches.(B) Corridors shall not exceed 150 feet in length from any resident unit to a seating or other common-use area.(C) Handrails must be installed at one or both sides of resident-use corridors. This Rule is not met as evidenced by:

OAR411-004-0020(2)(b) Physical Setting: Individual Accessible (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (b) The setting is physically accessible to an individual. This Rule is not met as evidenced by: Concerns were identified and the facility was provided with technical assistance in the following areas: (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (b) The setting is physically accessible to an individual.

OAR411-004-0020(2)(b) Physical Setting: Individual Accessible (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (b) The setting is physically accessible to an individual. This Rule is not met as evidenced by: