Print Inspection: CHOW001746

OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. Findings include, but are not limited to: During the CHOW survey, conducted 12/17/24 through 12/19/24, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number and severity of citations. Refer to deficiencies in report.

ED and BOM will ensure background checks are completed and cleared prior to scheduling employee(s), ED and BOM will ensure to gather all required documents at orientation utilizing checklist to verify. ED and BOM will monitor daily at stand up by conducting employee file audit(s) to ensure completion of necessary required paperwork ED will implement a weekend manager on duty schedule All dept heads will be educated by the RDO, RDHS, and VP Clinical Services on expectations of weekend MOD ED will ensure the corrections are completed and monitored.

OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals. This Rule is not met as evidenced by:

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure reasonable precautions were implemented to ensure a resident received sufficient assistance with bed mobility, during incontinent care, to maintain their health and safety for 1 of 1 sampled resident who was dependent for care (#3). Resident 3 expressed distress and anxiety during care related to how staff were moving the resident in bed. Resident 3 was admitted to the facility in 01/2014 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's 11/15/24 service plan, 09/17/24 through 11/26/24 observation notes, physician communications, and incident investigations were completed. The resident was noted to be dependent with all ADLs. The resident required two staff assistance for transfers and dressing and a Hoyer lift for transfers. The resident was nonverbal. The resident’s muscles and limbs were very tight to move, straighten and bend fully. The resident was noted to have anxiety and behaviors with ADL cares due to his/her confusion. Staff were instructed to tell the resident step by step what was occurring during care to help alleviate any distress. Observations of ADL care including incontinent care, bed mobility, Hoyer transfer and dressing were completed between 12/17/24 and 12/19/24 and showed the following: Afternoon incontinence care on 12/17/24: * The resident was assisted by two staff and a Hoyer from his/her wheelchair into his/her bed. * The resident required incontinence care and a clothing change during the observation. * The resident was turned side to side to remove and replace his/her brief, provide cleaning and change the resident’s pants. * The resident was positioned too close to the outer edge of the mattress during multiple rolls side to side. * On two occasions Staff 18 (CG) put a hand on the side of the resident’s head and used his/her head as leverage to help turn the resident, while the other hand was at the resident’s hip. Staff 18 was told by Staff 9 (CG) and by the surveyor not to use the resident’s head to help turn him/her. * When rolled to the right, the resident’s entire upper body and arms were observed hanging off the bed. Staff were standing on the right side of the bed near the resident’s waist. The resident’s torso was dangling off the bed when staff were asked by the surveyor, to adjust the resident. * When the resident was rolled to the right while lying on the very outer edge of the bed, s/he began to yell out, grab at staff and/or flail his/her arms. * The resident was not placed in the center of the bed, or his/her placement readjusted prior to providing care or rolling. Start of day dressing, incontinence care and mid-morning incontinence care on 12/18/24: * The resident was dressed for the day and his/her brief changed as part of his/her morning routine. * The resident’s position in bed was not checked or adjusted prior to rolling the resident for clothing and brief changes. * The resident was rolled to the left side with his/her head landing extremely close to the wall. The resident’s head did not contact the wall. The resident was making noises, yelling and moaning during care. The resident was not told what was occurring before it happened. * The resident was rolled to the right side but was extremely close to the edge. The resident showed signs of distress when turned to the right, was unstable and grabbing at staff clothing and bodies. The resident was heard moaning, yelling, and observed flailing his/her arms. * The resident was rolled so far to the right s/he was partially on his/her stomach. The resident’s face was pressed closely to the staff’s pants/leg and his/her yelling/crying out was muffled. * Staff 12 and 18 (CGs) were again asked by the surveyor to readjust the resident’s position to keep him/her away from the edge when rolling and to ensure the resident’s face was not up against the bedding or staff clothing/legs. * The side of the resident’s head was used to assist in a roll as previously observed on 12/17/24. Additionally, the back of the resident’s head/upper neck was used to help lift the resident up to adjust his/her shirt placement. * Staff 18 (CG) was told by the surveyor not to use the side of the resident’s head or the back of his/her neck for any position adjustments as it could cause injury. * Neither of the two staff taking care of the resident provided him/her information on what was occurring with care or spoke to the resident to try and soothe him/her when showing signs of distress and being upset during most of the care. * While agitated and calling out, the resident was grabbing at staff, his/her brief and putting hands near peri area. Staff 12 (CG) was observed to pull the residents sweatshirt up over the resident’s now crossed arms and place her own hand on top of the sweatshirt over the resident’s arms. The resident pulled his/her arms free, and staff did not attempt a similar move during the remainder of care. In an interview on 12/18/24, Staff 12 and Staff 18 indicated they understood the resident should be positioned away from the edge of the bed before rolling. In an interview on 12/18/24, Staff 1 (ED) and Staff 5 (RCC) were provided with information on the observations of care for Resident 3. Staff 1 and Staff 5 indicated the care staff should not be talking over the resident and should be telling the resident what was going on during care to help with distress. Staff 1 and Staff 5 acknowledged that the resident should not be rolled so closely to the edge of the bed, or any attempt made to restrain arms or hands with clothing. Staff 1 indicated additional training was required. Staff 1 and Staff 5 indicated they would be reviewing proper care of the resident with the staff observed as well as the staff normally assigned to the house. In an additional interview on 12/19/24, Staff 1 indicated they reviewed transfers and resident care at the staff meeting on 12/18/24 as well as working on individual trainings. An additional observation of morning care was completed on 12/19/24 with improvement in some areas of the transfer and provision of care. A draw sheet was utilized, and the resident was adjusted in bed prior to rolling side to side. The need to ensure staff took reasonable precautions to provide appropriate care to ensure the safety and well-being of a dependent resident, during ADL care, was discussed with Staff 1 (ED), Staff 2 (Health Services Director/LPN) and Staff 5 (RCC) on 12/18/24 and 12/19/24. The staff acknowledged the findings. Refer to C 200.

All staff will be educated by the ED and HSD on resident rights and dignity, including language,dignity with dining, and privacy/dignity with cares. Staff educated on providing care for resident #3 to minimize unpleasent feelings when providing care and transfers. All staff will receive this education at time of hire, and at least annually. ED will be responsible for ensuring corrections are completed and monitored.

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by:

RCC’s, HSD or Designee to ensure all staff have Notify palm pilots active and in good working order daily at shift change. ED or designee will educate all staff on the expectations of answering call lights. Call Light System Audits to Ensure System is Running Effectively & Staff are responding in a timely manner. • ED to perform Daily Audits through 6/15/2025 and address any call lights over 15 minutes with care staff • Weekly Audits through 7/2025 • Bi-Weekly Audits through 8/2025 • Monthly Audits Moving Forward Responsible Party: Executive Director, Health Services Director (HSD) or Designee

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by:

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure reasonable precautions were exercised against any condition that could threaten the health, safety, or welfare of residents, including ensuring resident call pendants alerted staff when residents used them to call for assistance, and to establish and implement an effective policy to ensure resident safety during times of extreme temperatures, including heat. This is a repeat citation. Findings include, but are not limited to: a. The call system in the Ponderosa cottage was reviewed on 08/13/25. An unsampled resident was observed to activate the call system via pull cord in the living space of his/her apartment at 2:32 pm. The wall unit audibly alerted and had a blinking red light. At 2:52 pm, 20 minutes after the call system was activated, no staff had entered the resident’s room to assist the resident. Multiple staff were interviewed at 3:04 pm and stated that when a resident utilized his/her pull cord or pendant, a notification should arrive on the facility phone, which was carried by one or more care staff depending on how many phones are currently working. The staff stated that there was one working phone on 08/13/25, and it was carried by a caregiver. The caregiver reviewed the phone and found there was no indication on the phone that the unsampled resident had pulled the cord at 2:32 pm. Staff stated that this happens frequently, and multiple unsampled residents consistently verbalized difficulty reaching staff to assist with addressing the residents’ ADL needs. In an interview on 08/14/25 at 10:40 am, Witness 8 (Resident’s Spouse) stated that his/her spouse consistently had difficulty reaching staff to assist with ADL care. S/he stated that within the past week, s/he had to physically get up to look for staff members to assist the resident after they utilized the call system and waited over 20 minutes with no response. On 08/14/25, the call system in the Alpine cottage was observed. The call pendant was pulled in room 6 at 10:58 am and was observed to be activated. At 11:18 am, 20 minutes later, staff had not responded. During interviews at 11:20 am, staff stated the system had not notified them that the call system had been activated for room 6. In an interview on 08/14/25 at 12:00 pm, Staff 31 (Administrator) and Staff 30 (Regional Director of Health Services) stated they were aware that the call system was not working, and no solution had been put into place to ensure residents were assisted when they utilized the call system to request help from facility staff. b. Two of the three cottages which made up the facility, Alpine and Beechwood, were endorsed memory care communities (MCCs) and had a secured outdoor courtyard which residents could access. (Keep this info) In an interview on 8/12/25 at 12:00 pm, Staff 30 (Regional Director of Health Services) provided the surveyor with a copy of the facility’s inclement weather policy, which stated “In temperatures above 85 degrees, the [courtyard] doors will be locked.” At 12:15 pm on 08/12/25, signs were observed on all courtyard doors which stated that the courtyard doors would be locked if the temperature was above 85 degrees. Between the hours of 12:30 pm and 1:25 pm on 08/12/25, the temperature in the outdoor courtyards reached between 90 and 93 degrees Fahrenheit. Multiple areas in the courtyards, including walking paths and benches, were not shaded and were exposed directly to the sun. In an interview on 08/12/25 at 2:14 pm, Staff 33 (CG) stated that residents entered and exited the courtyard “on their own”, including Resident 12 who enjoyed being outside and gardening during the summer. At 12:30 pm and 1:25 pm on 08/12/25, the doors to the courtyards were tested and found to be unlocked, with no visible system which would allow the door to be locked. In an interview on 08/12/25 at 1:35 pm, Staff 31 (Administrator) confirmed that there was no way to lock the courtyard doors, as per the facility policy and posted signage. The facility was unable to provide documented evidence of any other system in place to ensure resident safety in the courtyard in times of extreme heat. The need for the facility to ensure reasonable precautions were exercised against any condition that could threaten the health, safety, or welfare of residents, including ensuring resident call pendants alerted staff when residents used them to call for assistance, and to establish and implement an effective policy to ensure resident safety during times of extreme temperatures, including heat, was reviewed with Staff 28 (Director of Health Services/LPN), Staff 30, and Staff 31 on 08/14/25 at 12:00 pm. They acknowledged the findings.

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by:

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by: Based on observation, interview, and record review it was determined the facility failed to ensure a resident was treated with dignity and respect and maintained a safe and homelike environment during ADL care for 1 of 3 sampled residents (#3). Resident 3 experienced distress and abrupt handling during ADL care. Findings include, but are not limited to: Resident 3 was admitted to the facility in 01/2014 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's 11/15/24 service plan, 09/17/24 through 11/26/24 observation notes, physician communications, and incident investigations were completed. The resident was noted to be dependent with all ADLs. The resident required two staff assistance for transfers and dressing and a Hoyer lift for transfers. The resident was nonverbal. The resident’s muscles and limbs were very tight to move, straighten and bend fully. The resident was noted to have anxiety and behaviors with ADL cares due to his/her confusion. Staff were instructed to tell the resident step by step what was occurring during care to help alleviate any distress. Observations of ADL care including incontinence care, bed mobility, Hoyer transfer and dressing were completed between 12/17/24 and 12/19/24. a. The resident was dressed/undressed, had a brief change, cleaned and rolled side to side with minimal to no interaction from staff. Additionally, the resident required a Hoyer lift for transfers out of his/her bed and wheelchair. During several observations, the resident was moved with the lift without interaction from staff or verbal reassurance before or during transfers. Multiple instances of bed mobility showed the resident dangling off the bed, rolled over the edge of the bed with marginal support of torso, turned so far to the right that s/he was close to being on his/her stomach and/or the resident pulled so far to the right while at the edge that s/he was pointed towards the floor. The resident would flail around for something to hold onto and yell. One of these observations the resident’s face was so close to Staff 18’s pant leg and thigh that the resident’s yells were muffled, and his/her hands were unable to move due to the position of the resident’s body. The surveyor instructed staff to adjust the resident’s positioning to keep him/her away from the edge of the bed and to keep his/her face away from clothing, staff legs and bedding. b. The resident was abruptly turned and moved around the bed for care. Multiple occasions the side of the resident’s head was used as a contact point to try to move the resident. Staff were advised by the surveyor not to use the side of the resident’s head as a transfer point. c. The resident’s soiled brief was removed, and the resident left uncovered while additional wipes were located for clean-up. d. The resident was aggressively and abruptly cleaned after a bowel movement. The resident was not told what was happening, not advised wipes might be cold and not prepared for the next bit of care. The resident startled and made sounds when the wipes first touched his/her skin. e. The resident showed signs of distress during care. The resident was calling out and hitting out at staff. The resident’s sweatshirt was pulled up over his/her arms and briefly held in place before the resident pulled an arm free. There were no further attempts to restrain the resident. f. The resident was observed during three meals. Staff provided the resident with his/her pureed diet and thickened liquids. The staff provided bites that were larger than indicated by the service plan, had minimal to no interaction with the resident during the meal, rushed fluid intake and were task oriented rather than person oriented. g. The resident showed signs of pain and discomfort during his/her breakfast meal on 12/18/24. Soon after the resident began crying out a strong odor appeared around the resident. The resident ate less than 25% of his/her meal, would not take any additional bites and was wheeled near the living room and parked. The fecal odor around the resident was very strong. The surveyor informed the MT of the odor around the resident and that it began while the resident was having breakfast. Staff did not assist the resident with incontinence care until approximately 60 minutes after the odor first appeared and approximately 30 minutes after the MT was informed. When Staff 12 (CG) and Staff 18 (CG) transferred the resident to bed, it was determined the resident’s pants were soiled and required changing along with his/her brief. The resident’s pants were forcefully removed, and, in the process, fecal matter was flung about the resident’s bed. The resident required numerous turns and wipes to get all areas sufficiently clean. The resident was distressed throughout the process with some flailing of arms, grabbing at staff and vocalization of sounds. The staff continued to talk over the resident in English and Spanish but rarely to the resident himself/herself. In an interview on 12/18/24, Staff 1 (ED) and Staff 5 (RCC) were provided with information on the observations of care for Resident 3. Staff 1 and Staff 5 indicated the care staff should not be talking over the resident and should be telling the resident what was going on during care to help with distress. Staff 1 and Staff 5 acknowledged that the resident should not be rolled so closely to the edge of the bed, or any attempt made to restrain arms or hands with clothing. Staff 1 indicated additional training was required. Staff 1 and Staff 5 indicated they would be reviewing proper care of the resident with the staff observed as well as the staff normally assigned to the house. In an additional interview on 12/19/24, Staff 1 indicated they reviewed transfers and resident care at the staff meeting on 12/18/24 as well as working on individual trainings. An additional meal observation and care observation on 12/18/24 and 12/19/24 showed staff were seated in front of the resident and speaking with him/her about the meal. Smaller bites were offered more slowly, and single sips of fluids were offered one at a time. Staff were interacting with the resident more efficiently during ADL care and ensuring the resident was positioned away from the edge of the bed. The resident showed less distress with this observation of ADL care. The need to ensure staff treated residents with dignity and respect and provided a safe and home like environment when providing care was discussed with Staff 1, Staff 2 (Health Services Director/LPN) and Staff 5 on 12/18/24 and 12/19/24. The staff acknowledged the findings. Refer to C160.

All staff will be educated by the ED and HSD on resident rights and dignity, including language,dignity with dining, and privacy/dignity with cares. ED educated the caregivers on resident rights and providing personal care with dignity on 12/18/2025 All staff will receive this education at time of hire and at least annually. ED will ensure the corrections are completed and monitored.

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by:

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to report incidents of abuse to the local Seniors and People with Disabilities (SPD) office and failed to report injuries including injuries of unknown cause as suspected abuse to the local SPD office unless an immediate facility investigation reasonably concluded and documented the injuries were not the result of abuse for 4 of 5 sampled residents (#s 1, 3, 4 and 7) whose records were reviewed. Findings include but are not limited to: 1. Resident 1 was admitted to the facility in 09/2019 with diagnoses including dementia. The resident was noted to require the assistance of two staff for ADL cares. Review of the resident's 09/19/24 through 12/17/24 progress notes showed the following: * 11/07/24 - "Care staff reported to MT that when they assisted resident out of bed this morning, they noticed skin discoloration on the back of [his/her] left arm just above the elbow about the size of a golf ball appearing purple in color”; and * 11/29/24 - “During MT checks this MT observed skin discoloration on the top of the resident’s right hand. The discoloration is slightly larger than the size of a golf ball. Resident did not appear to be in any pain and was unable to provide information about how the discoloration occurred.” The facility lacked documented evidence the injuries of unknown cause were investigated to rule out abuse and neglect as cause of the injuries or reported to the local SPD office as suspected abuse. The need to report injuries of unknown cause as suspected abuse to the local SPD office unless an immediate facility investigation reasonably concluded and documented the injuries were not the result of abuse was discussed with Staff 1 (ED), Staff 2 (Health Services Director) and Staff 4 (Regional Director of Health Services) on 12/19/24. They acknowledged the findings. The facility was asked to report the injuries to SPD. Conformation was received by survey exit. 2. Resident 7 was admitted to the facility in 03/2024 with diagnoses including dementia with behavioral disturbances. Observations of the resident, interviews with staff, and review of the resident's 11/22/24 service plan, 09/22/24 through 12/10/24 observation notes, physician communications, and incident investigations were completed. The resident was noted to exhibit intermittent aggressive and/or sexually inappropriate behaviors. The resident required one staff assistance for ADL care and was able to independently ambulate around the facility with a walker. The resident could make some needs known and had poor safety awareness. Review of the resident's records showed the following: * An observation note dated 11/29/24, indicted the resident was walking the common area yelling that his/her roommate would touch Resident 7’s genitals. Staff told the resident not to discuss it with others. There was no investigation completed, and no report made to the local SPD office. The facility was asked to report the 11/29/24 incident to the local SPD office and provide the confirmation of the report. The need to ensure all incidents were promptly investigated to rule out abuse and/or neglect and reported when required, was discussed with Staff 1 (ED) and Staff 4 (Regional Director of Health Services) on 12/19/24. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 01/2014 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's 11/15/24 service plan, 09/17/24 through 11/26/24 observation notes, physician communications, and incident investigations were completed. The resident was noted to be dependent with all ADLs. The resident required two staff assistance for transfers and dressing and a Hoyer lift for transfers. The resident was nonverbal. The resident’s muscles and limbs were very tight to move, straighten and bend fully. The resident was noted to have anxiety and behaviors with ADL cares due to his/her confusion. Review of the resident's records showed the following: * An observation note dated 09/15/24 indicated the resident had “oozing spots on inner thighs…odd odor/discharge” from genitals. The resident was seen by their physician on 09/17/24 and Nystatin powder was initiated for the areas on the inner thighs. There was no investigation documented regarding the areas to determine cause and plan to prevent reoccurrence. The need to ensure all incidents and injuries of unknown cause were promptly investigated to rule out abuse and/or neglect and were documented, was discussed with Staff 1 (ED) and Staff 4 (Regional Director of Health Services) on 12/19/24. They acknowledged the findings. 4. Resident 4 was admitted to the facility 06/2024 with diagnoses including dementia. Review of the resident's records showed the following: * An observation note dated 11/19/24 indicated the resident had complaints of enlarged/swollen genitalia. Staff observed the area, the physician was notified, and the resident was sent to urgent care for evaluation. There was no investigation documented. The need to ensure all incidents and injuries of unknown cause were promptly investigated to rule out abuse and/or neglect and were documented, was discussed with Staff 1 (ED) and Staff 4 (Regional Director of Health Services) on 12/19/24. They acknowledged the findings.

ED and HSD will be educated by the Regional director of Health Services and the Rgional Director of Operations on incident investigation and reporting standards. Incident reports for Resident #1 was reported to APS on 12/18/2024. Resident #3 was evaluated by a licensed nurse on 9/16/24 and noted redness to groin area, ISP put in place to provide brief changes frequently throughout shifts. On 9/17/24 nurse visited resident #3 and ordered nystatin powder to areas in groin and thighs. Based on physician order it was determined no abuse or neglect had occurred. Incident report for #7 was reported to APS on 12/20/24 with TSP in place, Incident report for resident #4 was reported to APS on 12/20/24. All Staff will be educated on reporting standards by the ED and/or HSD. ED/HSD will review incident reports at least 5 days/week x 1 month, at least twice weekly x 1 month,and then weekly x 1 month at Daily Stand-up to ensure reportable incidents are reported timely. These will be discussed at the monthly continuous quality improvement meeting x 3 months.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to immediately report incidents of abuse to the local Seniors and People with Disabilities (SPD) office, failed to report injuries of unknown cause as suspected abuse to the local SPD office unless an immediate facility investigation reasonably concluded and documented the injuries were not the result of abuse, and take measures necessary to protect residents and prevent the reoccurrence of abuse or suspected abuse for 3 of 3 sampled residents (#s 8, 9, and 10) whose records were reviewed. This is a repeat citation. Findings include but are not limited to: 1. Resident 8 moved into the memory care community in 06/2023 with diagnoses including Alzheimer’s disease. The resident’s Observation notes, dated 02/17/25 through 05/01/25, and Incident Reports, dated 03/17/25 through 04/30/25, were reviewed and the following incidents were identified: * 03/17/25: Bruising to right top arm (reported to the local SPD office on 03/21/25, four days later); * 03/24/25: Resident to resident altercation; * 03/31/25: Elopement off of the unit (reported to the local SPD office on 04/08/25, eight days later); * 04/28/25: Lump on left side of hip; and * 04/30/25: Redness on lower left arm. There was no documented evidence the above incidents were immediately reported to the local SPD office, injuries of unknown cause were investigated to rule out abuse or suspected abuse and immediately reported to the local office if the investigation could not reasonably conclude the injuries were not the result of abuse, and/or take measures necessary to protect residents and prevent the reoccurrence of abuse or suspected abuse. On 05/06/25, the facility provided documentation that the incidents occurring 03/24/25, 04/28/25, and 04/30/25 were reported to the local SPD office. The need to immediately report incidents of abuse to the local SPD office, investigate injuries of unknown cause and report to the local office if the facility investigation was unable to reasonably rule out suspected abuse, and take measures necessary to protect residents and prevent the reoccurrence of abuse or suspected abuse with Staff 1 (ED) on 05/07/25 at approximately 11:45 am. She acknowledged the findings. 2. Resident 9 moved into the memory care community in 01/2024 with diagnoses including dementia. The resident’s Observation notes, dated 02/17/25 through 04/29/25, were reviewed and the following was identified: * 03/24/25: Resident to resident altercation. There was no documented evidence the above incident was immediately reported to the local SPD office, or the facility took the measures necessary to protect residents and prevent the reoccurrence of abuse or suspected abuse. On 05/06/25, the facility provided documentation that the incident was reported to the local SPD office. The need to immediately report incidents of abuse to the local SPD office and take measures necessary to protect residents and prevent the reoccurrence of abuse or suspected abuse with Staff 1 (ED) on 05/07/25 at approximately 11:45 am. She acknowledged the findings. 3. Resident 10 moved into the memory care community in 08/2020 with diagnoses including Alzheimer’s disease. The resident’s Observation notes, dated 02/17/25 through 05/04/25, and Incident Reports, dated 03/05/25 through 04/30/25, were reviewed and the following incident was identified: * 04/30/25: Wrist was swollen and red in color. There was no documented evidence the above incident was investigated to rule out abuse or suspected abuse and immediately reported to the local office if the investigation could not reasonably conclude the injuries were not the result of abuse. On 05/06/25, the facility provided documentation that the incident that occurred 04/30/25 was reported to the local SPD office. The need to investigate injuries of unknown cause and report to the local office if the facility investigation was unable to reasonably rule out suspected abuse was shared with Staff 1 (ED) on 05/06/25 at approximately 2:40 pm. She acknowledged the findings.

Identified incidents were sent to APS during the survey. ED will complete Oregon Care Partners abuse/neglect/reporting training by 6/06/2025 All incidents were reported while survey team was on site. ED will educate all staff on abuse/neglect training by 6/18/2025 . The BOM/designee will create a tracker list and monitor for completeness. ED/designee will investigate and self report to APS as required any report of potential abuse/neglect as required. This will be monitored by the RDHS/Designee at least 1 day/week x 4 weeks and then bi-weekly x 4 weeks starting on 6/01/2025. This will be monitored by review of incident reports, progress notes, and shift report logs daily during Clinical Huddle.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. 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 and preferences, provided clear direction to staff regarding the delivery of services, or was implemented for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5 and 7) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 09/2019 with diagnoses including dementia. The resident's 12/08/24 service plan was reviewed, observations made of the resident and interviews with staff occurred throughout the survey. The service plan was not reflective of the resident's current needs and preferences, was not implemented or lacked clear instructions to staff in the following areas: * Repositioning including use of a draw sheet while sitting in geriatric chair; * Positioning of geriatric chair while in common areas of the facility; * Incontinence care including use of barrier cream with brief changes; and * Hair care including use of headband verses hair tie. The need to ensure Resident 1's service plan was reflective of the resident’s needs, gave clear instruction to staff and was implemented was discussed with Staff 1 (ED), Staff 2 (Health Services Director) and Staff 4 (Regional Director of Health Services) on 12/19/24. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 08/2022 with diagnoses including dementia. The resident's 11/12/24 service plan was reviewed, observations made of the resident and interviews with staff occurred throughout the survey. The service plan was not reflective of the resident's current needs and preferences and lacked clear instruction to staff in the following areas: * Toileting schedule; * Dining including preference to sit separate from other residents, meal assistance; and * Best practices for proving ADL supports when resident was ambulating throughout the unit. The need to ensure Resident 2’s service plan was reflective and gave clear instruction to staff was discussed with Staff 1 (ED), Staff 2 (Health Services Director) and Staff 4 (Regional Director of Health Services) on 12/19/24. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 01/2013 with diagnoses including dementia. Observations of the resident, interviews with staff and review of the service plan, dated 11/15/24, showed the service plan was not reflective of the resident's current care needs, was not consistently implemented and/or did not provide clear direction to staff in the following areas: * Evacuation assistance; * Barrier cream, toileting and incontinence care; * Bed mobility, Hoyer use and positioning in the wheelchair and bed; * Floating heels and foot support in bed and wheelchair; * Behaviors including anxiety, striking out and distress with ADL care; * Hygiene, grooming and dental needs; * Dressing and bathing assistance; * Nonverbal communication from resident; * Meal assistance, positioning, size of bite, divided dish; and * Fall and safety interventions including bed alarm, scoop mattress, fall mat and low bed. The need to ensure resident service plans were reflective of current care needs, was consistently implemented and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 5 (RCC) on 12/18/24. They acknowledged the findings. 4. Resident 4 was admitted to the facility in 06/2024 with diagnoses including dementia. Observations of the resident, interviews with staff and review of the service plan, dated 11/25/24, 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: * Evacuation assistance; * Skin monitoring and edema; * Behaviors including agitation and sexually inappropriate contact; * Transfers, mobility and walker use; * Dressing, grooming and bathing assistance; * Toileting, incontinence care and nighttime needs; * Anxiety, sadness related to loss of spouse and searching for them; and * Fall and safety interventions. 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 5 (RCC) on 12/18/24. They acknowledged the findings. 5. Resident 7 was admitted to the facility in 03/2024 with diagnoses including dementia. Observations of the resident, interviews with staff and review of the service plan, dated 11/22/24, 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: * Evacuation assistance; * Exit seeking; * Sleep patterns and insomnia; * Behaviors including agitation and sexually inappropriate contact; * Transfers, knee buckling, mobility, walker compliance and gait belt use; * Dressing, grooming and bathing assistance; * Toileting, incontinence care and nighttime needs; and * Falls, safety interventions and awareness of resident location. 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 5 (RCC) on 12/18/24. They acknowledged the findings. 6. Resident 5 was admitted to the facility in 09/2019 with diagnoses including dementia and chronic kidney disease. The resident’s 10/19/24 service plan was reviewed. Observations of the resident and interviews with staff were completed during the survey. The service plan was not reflective of the resident's current status and did not provide clear direction to staff in the following areas: * Fall interventions including when to use fall mats; * Non-pharmaceutical interventions for pain; * Privacy preferences related to keeping the door open; * Ability to use the call light system; * Depression, including how it was exhibited and interventions when observed; * Preferences for use of a warmer for skin wipes; * Amount of time to sit up in the wheelchair; and * Safety checks for use of side rails. 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 4 (Regional Director of Health Services) on 12/19/24 at 2:55 pm. They acknowledged the findings.

The service plan(s) for resident(s) # 1, 2, 3, 4, 5 and 7 will be updated by RCC's, HSD's and ED to reflect needs and provide clear direction to care staff. This will be completed by 1/17/2025. The service plan for resident #1 was updated reflecting specific hair preferences, Geri chair sling, geri chair positioning and barrier cream instructions were added onto the care plan for resident #1 reflective of the barrier cream order. The service plan for resident #2 toileting schedule, dinning preferences, meal assistance needs have been included into residents plan and instruction on how to guide resident to provide ADL support when resident is ambulating. The Service plan for resident #3 was reviewed and added instructions on Evacuation assistance, additional training provided to care staff on use of barrier cream with incontinence care and repositioning in wheelchair/bed and hoyer use. Instructions added in plan for foot support when in bed and foot rest being utilized when out of bed. Behavioral plan revised, ADL care instructions revised to provide guidance on level of assistance needed. Resident #3's service plan revised to reflect residents form of communication. Residents service plan reflective of use of divider plate for meals. In service completed on meal service. The service plan for resident #4 revised to include instruction on evacuation, information regarding Edema and requiring monitoring. Behavioral plan, transfer ability, ambulation needs, ADL assistance and fall prevention plan have been revised. Resident #7's service plan was revised to reflect evacuation assistance needs, exit seeking, Sleep patterns and insomnia, Behavioral plan, Transfer needs, knee buckling, mobility, walker compliance and gait belt use, ADL assistance, Toileting/incontinence needs and Falls, safety interventions and awareness of resident location. Resident #5's service plan was revised to reflect Fall interventions including when to use fall mats, Non-pharmaceutical interventions for pain, Privacy preferences, Ability to use the call light system, Depression, including how it was exhibited and interventions when observed, Preferences for use of a warmer for skin wipes; Amount of time to sit up in the wheelchair; and Safety checks for use of side rails. Regional Director of Health Services will educate the ED and the HSD on person centered service planning. All direct care staff will be inservices by the ED and/or HSD on communicating changes in resident care so that service plans can be updated accordingly. ED/HSD will audit 10% of service plans x 2 months including staff interviews so that service plans are reflective of resident care needs.

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and preferences, provided clear direction regarding the delivery of services, or were implemented for 4 of 4 sampled residents (#s 8, 9, 10, and 11) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 11 moved into the facility in 12/2023 with diagnosis including aphasia following cerebral infraction (related to language disorder as a result of a stroke) and major depressive disorder. The resident's record, including the current service plan dated 03/07/25, Observation notes dated 02/17/25 through 04/30/25, and Change in Plan of Care documentation, was reviewed, observations were made, and interviews with Resident 11 and facility staff were conducted. The following was identified: The resident's service plan was not reflective of resident’s current needs and did not provide clear direction regarding the delivery of services in the following areas: * Mobility status and devices used that included a manual wheelchair; * Dining set-up assistance that included the use of an adult sippy cup, raised plate, oversized utensils, and use of clips to secure a “clothing protector” over a bib; * Use of an adult sippy cup in the resident’s room that included cleaning instructions; * Instruction related to resident being “uncomfortable” when an unsampled resident followed him/her around the facility; * Side rail instruction and safety precautions; * Vision loss in right eye and instruction to staff related to diagnosis; * Current use of assistive devices for activities and interests; and * Preference to receive assistance with toileting after lunch service. The need to ensure service plans were reflective of residents' current care needs and preferences and provided clear direction regarding the delivery of services was reviewed with Staff 1 (ED) on 05/07/25 at 10:12 am. She acknowledged the findings. 2. Resident 10 moved into the memory care community in 08/2020 with diagnoses including Alzheimer’s disease. The resident’s service plan, dated 02/19/25, and temporary service plans, dated 02/20/25 through 04/29/25, were reviewed. Resident 10 was observed, and staff were interviewed. The service plan was not reflective of the resident’s current needs, lacked clear instructions to staff, and/or was not implemented in the following areas: • Use of an air mattress; • Use of a floor mat; • Use of heel protectors including instruction on when it should be on or off; • Transfer status including one-person versus two-person assistance and use of a gait belt; • Toileting status including level of assistance required • Eating status; and • Dressing and undressing status. The need to ensure service plans were reflective of the resident’s needs, provided clear instruction to staff and were implemented was discussed with Staff 1 (ED) on 05/06/25 at approximately 2:40 pm. She acknowledged the findings. 3. Resident 8 moved into the memory care community in 06/2023 with diagnoses including Alzheimer’s disease. The resident’s service plan, dated 04/10/25, and temporary service plans, dated 03/17/25 through 05/04/25, were reviewed. Resident 8 was observed and staff were interviewed. The service plan was not reflective of the resident’s current needs or lacked clear instructions to staff in the following areas: * Use of glasses; * Interventions relating to the risk of elopement; * Interventions for agitation (e.g. allowing space to walk in facility, ruling out pain); * Spouse's involvement; * Instruction to staff relating to taking time to assist with ADLs as to negate behaviors; * Ability to be redirected; and * Behavioral interventions relating to resident to resident altercations (e.g. Resident 8 be kept in line of staff's sight when around any particular resident[s]). The need to ensure service plans were reflective of the resident’s needs and gave clear instruction to staff was discussed with Staff 1 (ED) on 05/07/25 at approximately 11:45 am. She acknowledged the findings. 4. Resident 9 moved into the memory care community in 01/2024 with diagnoses including dementia. The resident’s service plan, dated 03/17/25, and a temporary service plan, dated 03/11/25, was reviewed. Resident 9 was observed and staff were interviewed. The service plan was not reflective of the resident’s current needs or lacked clear instructions to staff in the following areas: * Chronic lower extremity swelling and interventions for staff to try; * Daily lotion application; * What causes agitation and how the resident exhibits it; and * Interventions for resistance to care in the mornings. The need to ensure service plans were reflective of the resident’s needs and gave clear instruction to staff was discussed with Staff 1 (ED) on 05/07/25 at approximately 11:45 am. She acknowledged the findings.

HSD/Designee will update resident #8, 9, 10, and 11 service plans. The ED/Designee to audit all evaluations/service plans to ensure that all required items are captured with input from care staff, programming staff, resident and families. After the initial audit, the ED/Designee will audit 10% of resident service plans x 3 months to make sure changes are captured and services reflect current need.

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 and preferences, provided clear direction regarding the delivery of services, and/or were implemented for 3 of 3 sampled residents (#s 1, 12, and 13). This is a repeat citation. Findings include, but are not limited to: In an interview on 08/14/25 at 12:00 pm, Staff 28 (Director of Health Services/LPN) stated that the resident’s service plans and evaluations were separate documents, and both documents were included in the service plan binders available to all staff. She stated that staff were instructed to review both documents. The term “service plan,” as referenced below, refers to both the service plan and evaluation as documents instructing staff on the provision of care for residents. 1. Resident 1 moved into the facility in 09/2019 with diagnoses including dementia. During the acuity interview on 08/12/25, Resident 1 was identified as needing a mechanical lift and assistance from two care staff for care and transfers, was non-ambulatory, had a history of impaired skin integrity including history of wounds on his/her heels, and required full feeding assistance during meals and snacks. The resident's current service plan, dated 06/18/25, and TSPs dated 06/18/25 through 08/12/25 were reviewed, the resident was observed, and staff were interviewed. The resident’s service plan did not provide clear direction to staff and/or was not being implemented in the following areas: * Use of protective soft boots to decrease pressure on his/her heels; * Use of a headband instead of a hair tie due to the resident’s history of placing a hair tie in his/her mouth; * Use of a clothing protector during meals and snacks; and * Activity engagement. The need to ensure service plans provided clear direction regarding the delivery of services and were implemented was reviewed with Staff 28, Staff 30 (Regional Director of Health Services), and Staff 31 (Administrator) on 08/14/25 at 12:00 pm. They acknowledged the findings. 2. Resident 12 moved into the facility in 06/2023 with diagnoses including dementia. The resident was identified during the acuity interview on 08/12/25 as having a history of behaviors and resident-to-resident altercations. The resident's current service plan, dated 07/28/25, and TSPs dated 07/28/25 through 08/12/25 were reviewed, the resident was observed, and staff were interviewed. The resident’s service plan did not reflect his/her current needs and preferences and/or was not being implemented in the following areas: * Frequency of toileting and incontinence care; * Behavior plan; and * Activity engagement. The need to ensure service plans were reflective of residents’ needs and preferences and were implemented was reviewed with Staff 28, Staff 30 (Regional Director of Health Services), and Staff 31 (Administrator) on 08/14/25 at 12:00 pm. They acknowledged the findings. 3. Resident 13 moved into the facility in 04/2024 with diagnoses including dementia. The resident was identified during the acuity interview as having a history of falls, pureed diet, and requiring feeding assistance. The resident's current service plan, dated 07/30/25, and TSPs dated 07/30/25 through 08/12/25 were reviewed, the resident was observed and interviewed, and staff were interviewed. The resident’s service plan did not reflect his/her current needs and preferences and/or was not being implemented in the following areas: * Use of fall interventions, including fall mat; * History of weight loss; * Cueing from staff seated next to him/her during meals; and * Use of a straw with drinks. The need to ensure service plans were reflective of the resident’s needs and preferences and were implemented was reviewed with Staff 28, Staff 30 (Regional Director of Health Services), and Staff 31 (Administrator) on 08/14/25 at 12:00 pm. They acknowledged the findings.

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 411-054-0040 (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 ensure actions or interventions were determined, documented, and communicated with staff on all shifts for changes of condition and failed to ensure changes were monitored, with progress noted at least weekly until resolution, and/or referred to the facility nurse for a significant change of condition for 6 of 6 sampled residents (#1, 2, 3, 4, 5, and 7) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 01/2014 with diagnoses including dementia. The resident's 11/15/24 service plan, 09/17/24 through 11/26/24 observation notes, incident investigation notes and physician communications were reviewed. a. The resident experienced multiple short-term changes without noted progress at least weekly until resolved, and/or lacked resident-specific directions to staff in the following areas: * Breast rash; * Vomiting; * Constipation; * Hospital/Emergency Department return; and * Rash, sores, discharge and redness to the inner thighs and genitals. b. The resident experienced a seven pound weight loss between 07/22/24 and 08/19/24 which equaled a 5.25% weight loss in one month, a 10 pound weight loss from 09/23/24 and 10/21/24 which equaled a 7.5% loss in one month, a seven pound weight gain between 10/21/24 and 11/04/24 which equaled a 5.69% gain in less than two weeks and a 7.4 pound loss between 11/25/24 and 12/19/24 which equaled a 5.89% weight loss in one month. The resident’s significant weight losses and gain were not reported to the facility RN for completion of a significant change of condition assessment. The need to ensure short-term changes of condition had documentation of weekly progress until resolution, provided clear, resident-specific directions to staff, and was referred to the facility RN for significant weight changes was discussed with Staff 1 (ED), Staff 4 (Regional Director of Health Services) and Staff 5 (RCC) on 12/18/24 and 12/19/24. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 06/2024 with diagnoses including dementia. The resident's 11/25/24 service plan, 09/19/24 through 12/16/24 observation notes, incident investigations and physician communications were reviewed. The resident experienced multiple short-term changes without noted progress at least weekly until resolved, and/or lacked resident-specific directions to staff in the following areas: * Medication changes * Falls; * ER/Hospital return; * Knee pain; * “Discoloration” to the left thigh and buttock and “bruise” to the left leg; * Enlarged/swollen genitals and edema; and * Palliative care admission. The need to ensure short-term changes of condition had documentation of weekly progress until resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED), Staff 4 (Regional Director of Health Services) and Staff 5 (RCC) on 12/18/24 and 12/19/24. They acknowledged the findings. 3. Resident 7 was admitted to the facility in 03/2024 with diagnoses including dementia. The resident's 11/22/24 service plan, 09/22/24 through 12/10/24 observation notes, incident investigations and physician communications were reviewed. The resident experienced multiple short-term changes without noted progress at least weekly until resolved, and/or lacked resident-specific directions to staff in the following areas: * Agitation, threatening others and yelling; * Chest pain and shoulder pain; * Sexual behaviors and entering other residents’ apartments; * Increased confusion; * Medication changes: and * Falls. The need to ensure short-term changes of condition had documentation of weekly progress until resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED), Staff 4 (Regional Director of Health Services) and Staff 5 (RCC) on 12/18/24 and 12/19/24.They acknowledged the findings. 4. Resident 1 was admitted to the facility in 09/2019 with diagnoses including dementia. Progress notes dated 09/19/24 through 12/17/24, 12/08/24 service plan, and Interim Service Plans (ISP’s) were reviewed and revealed the resident experienced the following short-term changes of condition in the review period: * 10/19/24 - Excoriation to left buttock; * 10/21/24 - “Dime sized skin tear on second toe, skin discoloration on big toe and fourth toe on right foot”; * 10/25/24 - New medication order, “start Nystatin powder [for rash] apply three times a day to inner thighs and groin between folds”; * 11/07/24 - “Skin discoloration back of left arm just above elbow, size of a golf ball”; and * 11/29/24 - “Skin discoloration top of right-hand golf ball sized”. The facility lacked documented evidence each concern had interventions or actions developed and communicated to staff on each shift, and the changes were monitored with progress noted at least weekly through resolution. The need to ensure short-term changes of condition had interventions or actions developed and communicated to staff on each shift and documentation to reflect monitoring at least weekly through resolution was discussed with Staff 1 (ED), Staff 2 (Health Services Director) and Staff 4 (Regional Director of Health Services) on 12/19/24. They acknowledged the findings. 5. Resident 2 was admitted to the facility in 08/2022 with diagnoses including dementia. Progress notes dated 09/26/24 through 12/16/24, 11/12/24 service plan, and Interim Service Plans (ISP’s) were reviewed and revealed the resident experienced redness to right forearm on 11/01/24. The facility lacked documented evidence the skin condition was monitored with progress noted at least weekly. The need to ensure short-term changes of condition were monitored with progress noted at least weekly through resolution was discussed with Staff 1 (ED), Staff 2 (Health Services Director) and Staff 4 (Regional Director of Health Services) on 12/19/24. They acknowledged the findings. 6. Resident 5 was admitted to the facility in 09/2019 with diagnoses including dementia and chronic kidney disease. The resident's 10/19/24 service plan and progress notes dated 09/20/24 through 11/27/24 were reviewed. The following short-term changes of condition lacked actions or interventions determined: * 10/02/24 - Cephalexin (for infection); * 10/04/24 - “Possible toe infection”; and * 10/31/24 - “Popped blister” on lower buttock. The need to ensure changes of condition had actions or interventions determined was discussed with Staff 1 (ED) and Staff 4 (Regional Director of Health Services) on 12/19/24 at 2:55 pm. They acknowledged the findings. .

ED and HSD will take the Change of Condition courses on NurseLearn. Service plan updated on 1/17/2025 for residents #1, 2, 3, 4, 5 and 7. The RDHS will educate the ED and HSD on referral of change of conditions to the RN. Direct care staff will be inserviced by the ED/HSD on reporting change of condition. ED, HSD and RCC's will review the observation notes at least 5 days per week, any short term or significant change of condition will be referred to the RN by the HSD and/or ED and documentation will reflect that referral.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to determine what resident-specific actions or interventions were needed for a resident following a short-term change of condition, communicate the determined actions or interventions, and document progress at least weekly until the condition resolved for 4 of 4 sampled residents (#s 8, 9, 10, and 11) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to: 1. Resident 10 moved into the memory care community in 08/2020 with diagnoses including Alzheimer’s disease. Review of the resident's clinical record including Observation notes, dated 02/17/25 through 05/04/25, service plan, updated on 02/19/25, temporary service plans, and 04/01/25 through 05/05/25 MARs were completed during the survey. a. The facility failed to determine and document what actions or interventions were needed for short-term changes of condition, to communicate resident-specific instructions and interventions to staff on each shift, and/or to monitor the change of condition, at least weekly, until resolved for the following changes of condition: • 04/15/25: Multiple medications were discontinued including scheduled pain medication and eye drop; • 04/30/25: Diet was changed to a mechanical soft diet; and • Weight loss between 03/05/25 and 05/05/25. b. The facility failed to monitor changes of condition, at least weekly, until resolution for the following: • 03/04/25: Increased the dosage of Remeron, appetite stimulation; and • 04/02/25: Episode of nose blood. The need to ensure the facility determined and documented what actions or interventions were needed for short-term changes of condition, communicated resident-specific instructions and interventions to staff on each shift, and/or monitored the change of condition, at least weekly, until resolved was discussed with Staff 1 (ED) on 05/06/25 at 2:40 pm. She acknowledged the findings. 2. Resident 8 moved into the memory care community in 06/2023 with diagnoses including Alzheimer’s disease. The resident’s service plan, dated 04/10/25, temporary service plans, dated 03/17/25 through 05/04/25, Observation notes, dated 02/17/25 through 05/01/25, and Incident Reports, dated 03/17/25 through 04/30/25, were reviewed during the survey. The facility failed to determine and document what actions or interventions were needed for short-term changes of condition, to communicate resident-specific instructions and interventions to staff on each shift, and/or to monitor the change of condition, at least weekly, until resolved for the following changes of condition: * 03/17/25: Bruising to right, upper arm; * 03/24/25: Resident to resident altercation; * 03/31/25: Elopement off of the unit; * 04/07/25: Witnessed fall; * 04/09/25: Unwitnessed fall; * 04/16/25: Witnessed fall; * 04/17/25: Resident to resident altercation; * 04/21/25: Unwitnessed fall; and * 04/28/25: Resident to resident altercation. The need to ensure the facility determined and documented what actions or interventions were needed for the short-term changes of condition, to communicate resident-specific instructions and interventions to staff on each shift, and to monitor the change of condition, at least weekly, until resolved was discussed with Staff 1 (ED) on 05/07/25 at approximately 11:45 am. She acknowledged the findings. 3. Resident 9 moved into the memory care community in 01/2024 with diagnoses including dementia. The resident’s service plan, dated 03/17/25, a temporary service plan, dated 03/11/25, and Observation notes, dated 02/17/25 through 04/29/25, were reviewed during the survey. The facility failed to determine and document what actions or interventions were needed for short-term changes of condition, to communicate resident-specific instructions and interventions to staff on each shift, and/or to monitor the change of condition, at least weekly, until resolved for the following changes of condition: * 03/11/25: Swollen left foot; * 03/24/25: Resident to resident altercation; and * 04/17/25: Resident to resident altercation. The need to ensure the facility determined and documented what actions or interventions were needed for the short-term changes of condition, to communicate resident-specific instructions and interventions to staff on each shift, and to monitor the change of condition, at least weekly, until resolved was discussed with Staff 1 (ED) on 05/07/25 at approximately 11:45 am. She acknowledged the findings. 4. Resident 11 moved into the facility in 12/2023 with diagnosis including aphasia following cerebral infraction (related to language disorder as a result of a stroke) and major depressive disorder. The resident's record, including the current service plan dated 03/07/25, Observation notes, dated 02/17/25 through 04/30/25, and temporary service plans documentation, was reviewed, observations were made, and interviews with Resident 11 and facility staff were conducted. The following was identified: * 02/24/25: Canker sore on inner cheek and shaved tooth; * 03/07/25: Side rails installed for bedside mobility; * 03/10/25: Chapped skin on right side of mouth and open area right side of lip; * 03/10/25: New medications including ondansetron (to prevent vomiting) and loperamide (for diarrhea); * 03/18/25: Scratches on thigh; * 03/27/25: Difficulty seeing, “right eye has blurry vision”; * 04/06/25: New behavior related to stress; * 04/10/25: Fall in bathroom; * 04/10/25: Skin tear on right hand near thumb; and * 04/12/25: New behavior including agitation resident is “uncomfortable” with an unsampled resident “following” him/her around the facility. The need to ensure the facility identified, determined, documented, and communicated the determined action or intervention to staff, and documented progress until resolution was reviewed with Staff 1 (ED) on 05/07/25 at 10:12 am. She acknowledged the findings

ED/Designee will inservice all staff on Change of Condition and reporting to the supervisor. The ED/Nurse/Designee will be educated by the RDHS/Designee on referral to the RN for short term or long term change of condition. Clinical huddle will be held and attended by the ED/HSD/Designees at least 4/days per week to review observation notes, short term or significant change of condition that will be referred to RN by HSD and/or ED and documentation will reflect referral. ED and HSD will complete Nurselearn courses related to resident Change of Condition.

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 observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed timely and documented findings, resident status, and interventions made as a result of the assessment for 1 of 3 sampled residents (#3) who experienced significant changes of condition. Resident 3 experienced continued severe weight changes without intervention. Findings include, but are not limited to: Resident 3 was admitted to the facility in 01/2014 with diagnoses including dementia. Review of the resident’s service plan dated 11/15/24, observation notes, physician communications, RN notes and weight records dated 09/17/24 through 11/26/24 were completed. The resident required full assistance from staff for all ADL care. The resident required one staff assistance for all food and fluid intake. The resident received a pureed diet and nectar thick liquids for all snacks and meals. Multiple daily observations of the resident between 11/17/24 and 11/19/24 showed the resident up in his/her wheelchair and reclined back approximately 45 degrees. The resident was dependent for all care. Staff would assist the resident to his/her wheelchair after providing ADL care. The resident was observed during two breakfast meals, two lunch meals and part of a dinner meal. The resident did not initiate any intake on his/her own. Staff provided total assistance with all intakes. The resident received pureed food in a three-compartment plate with raised sides. The staff were observed to offer the resident bites without much interaction. Fluids were alternated with bites of food. The resident took single sips from the cups offered. The resident did not appear able to complete successive sips. The resident ate between 25% and 50% of the meals offered. One meal staff reported the resident ate 100%, the dishes were cleared before an observation was made. The resident was not observed to receive snacks in the morning or afternoon during survey. The resident was brought to breakfast later in the morning, not long before the scheduled snack time, and provided his/her breakfast meal. Weight records reviewed from 07/22/24 through 12/19/24 were reviewed and showed the following: * A weight of 133.2 pounds on 07/22/24 and a weight of 126.2 pounds on 08/19/24. This constituted a seven pound, 5.25% severe weight loss in one month. * A weight of 133 pounds on 09/23/24 and a weight of 123 pounds on 10/21/24. This constituted a 10 pound, 7.5% severe weight loss in one month. * A weight of 123 pounds on 10/21/24 and a weight of 130 pounds on 11/04/24. This constituted a seven pound, 5.69% severe increase in less than two weeks. * The resident’s weight on 11/25/24 was documented as 125.6 pounds. * A current weight was requested from the facility. The resident’s weight on 12/19/24 was observed and documented as 118.2 pounds. This constituted a 7.4 pound, 5.89% severe loss from the last recorded weight. The resident received Boost health shakes which were held and no longer administered on 09/23/24 due to swallowing concerns related to the thin consistency. The resident was noted to be placed on weekly weights prior to June 2024. The weekly weights were discontinued on 11/25/24. In interviews on 12/17/24 and 12/18/24, Staff 9 (CG), Staff 18 (CG) and Staff 22 (CG) indicated the resident required full staff assistance to eat. The resident could not feed himself/herself due to cognition, confusion, and physical limitations. The staff indicated the resident did not generally have very good intake, but it did vary. Staff 22 indicated the resident ate 100% of his/her lunch meal on 12/18/24 but had not eaten well for breakfast. In an interview on 12/19/24, Staff 4 (Regional Director of Health Services) indicated the current RN was not made aware of the resident’s changes in weight. Reports were normally pulled near the beginning of the month for monthly weight review. Staff 4 stated Staff 2 (Health Services Director/LPN) would be responsible for pulling additional reports for the weekly weights, checking weights and reporting any issues or significant changes to the current facility RN. In an interview on 12/19/24, Staff 3 (RN) indicated she was not aware of the significant changes in the resident’s weights over the last few months. The reports she had reviewed looked only at the beginning of the month so other weights during the month were not on her radar. Staff 3 assisted to get a current weight on the resident, restarted weekly weights and would look into nutritional supplements once she was able to get a baseline for the resident’s weight. Staff 3 wanted to observe the weights as they were completed to ensure proper technique and calculations were being completed. The resident was not interviewable due to cognitive impairment and non-verbal status. The facility failed to ensure an RN assessment was completed for the severe weight changes from July 2024 to November 2024 which documented findings, resident status, and interventions made as a result of the assessment. The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (ED), Staff 3, Staff 4 and Staff 5 (RCC) on 12/18/24 and 12/19/24. The staff acknowledged the findings.

ED and HSD will take the Change of Condition courses on NurseLearn. RN assessed resident #3 on 12/19/2024 and weekly after that with additional monitoring. The RDHS will educate the ED and HSD on referral of change of conditions to the RN. Direct care staff will be inserviced by the ED/HSD on reporting change of condition. ED, HSD and RCC's will review the observation notes at least 5 days per week, any short term or significant change of condition will be referred to the RN by the HSD and/or ED and documentation will reflect that referral.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure a Registered Nurse assessed, documented findings and developed appropriate interventions for 1 of 2 sampled residents (# 10) who experienced an overall significant change in condition. This is a repeat citation. Findings include, but are not limited to: Resident 10 moved into the memory care community in 08/2020 with diagnoses including Alzheimer’s disease. Observations of the resident, from 05/05/25 to 05/07/25, showed the resident required staff assistance for transfers, meal intake and bathroom use with the help of two staff members. During the survey, Staff 6 (RCC) and Staff 27 (MA/CG) reported the resident had an overall decline in condition approximately two to four weeks ago, specifically in the following areas: * The resident was needing additional staff assistance with transfer, meal intake, bladder and bowel management and dressing. Those multiple changes represented the resident experienced a significant change of condition. There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment. The need to ensure a RN assessment was completed for residents who experienced a significant change of condition was discussed with Staff 1 (ED) on 05/07/25 at 9:55 am. She acknowledged the findings. On 05/07/25 at 11:18 am, the RN assessment was provided by Staff 6 (RCC), and she reported the assessment was completed that morning.

ED/Designee will inservice all staff on Change of Condition and reporting to the supervisor. The ED/Nurse/Designee will be educated by the RDHS/Designee on referral to the RN for short term or long term change of condition. Clinical huddle will be held and attended by the ED/HSD/Designees at least 4/days per week to review observation notes, short term or significant change of condition that will be referred to RN by HSD and/or ED and documentation will reflect referral. ED and HSD will continue to complete Nurselearn courses related to resident Change of Condition.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed in a timely manner for 1 of 1 sampled resident (#1) who experienced a significant change of condition. This is a repeat citation. Findings include, but are not limited to: Resident 1 was admitted to the facility in 09/2019 with diagnoses including dementia. During the acuity interview on 08/12/25, the resident was identified as having a Stage 2 pressure ulcer, which was new for the resident. The resident was identified as requiring a mechanical lift and two-person assistance from care staff for care, transfers, and repositioning. The resident’s service plan, dated 07/30/25, and 07/21/25 through 08/12/25 temporary service plans (TSPs), observation notes, skin tracking, and assessments were reviewed, the resident was observed, and staff were interviewed. On 07/24/25, a MT documented in the resident’s observation notes that an open wound had been identified on the resident’s left coccyx. An incident report completed the same day stated the wound was a pressure injury, and the health services director had evaluated the wound. A skin check form from 07/24/25, completed by Staff 28 (Director of Health Services/LPN), confirmed that there was an open area and noted that the “community RN has been notified of new potential pressure-related injury.” This indicated that the wound was a Stage 2, or open, pressure ulcer, which was a significant change of condition and required assessment by an RN. There was no documented evidence that an RN completed an assessment of the pressure-related injury in a timely manner, with all required components documented including findings, resident status, and interventions made as a result of the assessment. On 08/04/25, 11 days after the pressure ulcer was first identified, a facility RN completed a significant change of condition assessment. During an interview on 08/14/25 with Staff 28, Staff 30 (Regional Director of Health Services), and Staff 31 (Administrator), no additional information was provided as to why the significant change of condition was not assessed in a timely manner. The need to ensure an RN assessment was completed in a timely manner for all significant changes of condition was reviewed with Staff 28, Staff 30, and Staff 31 on 08/14/25 at 12:00 pm. They acknowledged the findings.

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 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to follow established infection prevention and control protocols to ensure a safe, sanitary, and comfortable environment for 2 of 3 sampled residents (#s 3 and 5) whose ADL care was observed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 01/2014 with diagnoses including dementia. On 12/17/24 at approximately 1:20 pm, the surveyor observed two caregivers provide incontinence care to Resident 3. During the process, Staff 9 (CG) assisted Staff 18 (CG) to remove the resident’s soiled/wet pants and soiled incontinence brief. The resident’s soiled pants were put directly on the carpeted floor and the brief was put in a garbage sack. Staff 18 failed to consistently change his gloves between dirty and clean tasks, such as after cleaning the resident’s perineal area and bottom and the removal of soiled items from the resident. Staff 18 touched the clean pants and brief before he was cued by Staff 9 to change his gloves. Staff 9 attempted to carry the wet pants to the laundry unbagged. The staff member was asked to put the pants in a bag before leaving the room and complied. Observations on 12/18/24 of ADL care at approximately 9:07 am and again at 10:47 am showed the following: * Glove changes between clean and dirty tasks were inconsistently completed by Staff 18. * Gloves used to remove soiled items and/or clean up the resident were used to touch clean briefs, clothes and/or bedding. Staff changed the gloves when asked to do so. * Soiled pants with both feces and urine were pulled off the resident and feces fell onto the bed, blanket and Hoyer sling pad. * The soiled pants were pulled through the air without determining what was falling out of the pants. Staff 12 stopped Staff 18 and informed him there was feces in the resident’s pants. * A wipe was used to grab the feces off the resident’s bed and put in the trash. * The resident’s Hoyer sling had a brown substance on it. When staff were asked if the sling was clean and free of feces, they confirmed it was. However, when the resident was done being changed Staff 9 indicated they were changing the sling. The sling was taken to the laundry room in a bag with the resident’s pants. An observation on 12/19/24 at approximately 9:03 am showed the following: * The blanket covering the resident had a brown, crusty substance on the inside section of the blanket. * Staff 18 was asked what was on the resident’s blanket and indicated after looking closely and scratching at the stain that it was probably food. The blanket was removed from the resident and placed in his/her recliner chair along with other items. * After the resident was changed and dressed, the resident’s pajamas and the blanket with the brown substance, were removed from the room by staff. Staff 18 held the pile of laundry close to his body and carried the items to the laundry room. The items were not bagged or in any other type of receptacle. Staff 12 and 18 indicated soiled items were put in bags. The need to ensure staff consistently used proper infection control and universal precautions when incontinence care was provided was discussed with Staff 1 (ED) and Staff 5 (RCC) on 12/18/24. They acknowledged appropriate infection control practices were not being followed. 2. Resident 5 was admitted to the facility in 09/2019 with diagnoses including dementia and chronic kidney disease. A review of his/her current service plan and interviews with staff revealed s/he was dependent on staff for all ADL care, including two person assist with toileting. On 12/19/24 at 9:40 am, two staff were observed providing incontinence care for Resident 5 in bed. One staff failed to change gloves after wiping fecal matter from Resident 5’s bottom area. While wearing the same soiled gloves, the staff then touched resident’s legs, heel protectors, side rail and blanket. The need to ensure infection prevention and control protocols were followed was discussed with Staff 1 and Staff 4 (Regional Director of Health Services) on 12/19/24 at 2:55 pm. They acknowledged the findings.

The ED and/or HSD will inservice all staff on infection control measures. The ED and HSD will each Observe 2 random care staff per week providing incontinence care x 8 weeks, 1 staff per week x 4 weeks, and then 1 x per month until compliance is achieved. ED/HSD will ensure corrections are completed and monitored and results will be brought to the continuous quality improvement meeting monthly x 3 months.

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by:

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by: Based on observation, interview and record review it was determined the facility failed to ensure devices with restraining qualities were assessed at least quarterly by an RN, OT or PT to determine safety of the device, the risks vs benefits for the resident and if the least restrictive option was utilized for 2 of 3 sampled residents (#s 3 and 5). Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 01/2014 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's service plan dated 11/15/24 showed the resident had a scoop mattress with raised sides at the head and foot of the mattress. A small gap was present between the upper and lower sections of the raised sides. Additionally, the resident had a high back, tilt in space wheelchair which allowed staff to recline the resident at a variety of different angles. The resident was unable to express any information regarding the devices. The resident’s cognition was significantly impaired and s/he required full assistance from staff for all ADL care including feeding of meals and two person assistance for transfers and dressing. Review of the resident's record showed no documented assessment or evaluation of the scoop mattress or the tilt in space wheelchair. The resident’s service plan did not provide information to staff related to either device, safety/maintenance items to watch for or how to use the device with the resident. The need for a PT, RN or OT to complete an assessment of any device with restraining qualities at least quarterly, was discussed with Staff 1 (ED), Staff 4 (Regional Director of Health Services) and Staff 5 (RCC) on 12/18/24 and 12/19/24. The staff acknowledged the findings. 2. Resident 5 was admitted to the facility in 09/2019 with diagnoses including dementia and chronic kidney disease. On 12/17/24 Resident 5 was observed to have a half side rail in the up position on the right side of the hospital bed. A current assessment for the side rail was requested on 12/18/24 at 1:25 pm. The facility provided the initial assessment for the side rail, completed on 02/08/24. On 12/18/24, Staff 4 (Regional Director of Health Services) confirmed there was no documented evidence a quarterly evaluation for Resident 5’s side rail had been completed since the initial assessment. She indicated Staff 3 (RN) was evaluating Resident 5 for the side rail. No further documentation was provided. The need to ensure an evaluation of any device with restraining qualities was evaluated at least quarterly, was discussed with Staff 1 (ED) and Staff 4 on 12/19/24 at 2:55 pm. They acknowledged the findings.

ED and HSD will be inserviced by the Regional Director of Health Services/Regional Director of Operations on supportive devices and devices with restraining qualities and the procedure for maintaining a restraint free environment. RN completed a device assessment for resident #3 on 12/19/2024. LN completed assessment on 2/3/25 for the supportive device for resident #5 and determined resident was not able to utilize this for mobility purposes. Device was removed. The HSD/designee will refer any devices of restraining qualities to the RN for initial asessment, and assessments will be done quarterly from there. The HSD/designee will do a full audit for devices with restraining qualities and refer to the RN for follow up.

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by:

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure they accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5) whose Acuity Based Staffing Tool (ABST) was reviewed. Findings include, but are not limited to: The facility's ABST was reviewed and discussed with Staff 1 (ED) and Staff 4 (Regional Director of Health Services) on 12/19/24 at 12:45 pm. Review of Residents 1, 2, 3, 4 and 5’s ABST input revealed multiple ADLs were not reflective of the residents' evaluated care needs. The need to ensure the facility's ABST addressed all evaluated care needs of residents, including the amount of staff time needed to provide care, was discussed with Staff 1 and Staff 4 on 12/19/24. They acknowledged the findings. No further information was provided.

The service plan(s) for resident(s) # 1, 2, 3, 4, 5 and 7 will be updated to reflect needs and provide clear direction to care staff. This will be completed by RCC, HSD and ED by 1/17/2025 The ED/designee is responsible to update the ABST prior to admission, quarterly, and with any change in condition. The ODHS ABST tool will be audited by the ED/HSD/designee with each service plan update and the staffing pattern will be adjusted accordingly.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure they accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan for 4 of 4 sampled residents (#s 8, 9, 10, and 11) whose Acuity Based Staffing Tool (ABST) was reviewed. This is a repeat citation. Findings include, but are not limited to: Review of Resident 8, 9, 10, and 11’s ABST revealed multiple care elements that did not accurately capture the care time needed to complete the tasks. The need to ensure the facility's ABST addressed all evaluated care needs of residents, including the amount of staff time needed to provide care, was discussed with Staff 1 (ED) on 05/07/25. She acknowledged the findings.

HSD or designee will update residents 8, 9, 10 and 11 to reflect appropriate time for care elements. ED/Designee will audit 10% of resident evaluations/service plans per month x 3 months to ensure accuracy of services provided and time of care provided. ED/Designee will ensure that staffing meets or exceeds the ABST tool to meet resident's scheduled and unscheduled need ED/HSD/designee will update the ABST prior to move in, every quarter with service plan updates and with changes in condition.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to accurately capture care time and care elements that staff were providing to each resident as outlined in each individual service plan for 3 of 3 sampled residents (#s 1, 12, and 13) whose Acuity Based Staffing Tool (ABST) was reviewed. This is a repeat citation. Findings include, but are not limited to: A review of Resident 1, 12, and 13’s ABST and service plans, observations of the residents, and interviews with staff revealed multiple care elements that did not accurately capture the care time needed to complete the tasks. The need to ensure the facility accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan was reviewed with Staff 28 (Director of Health Services/LPN), Staff 30 (Regional Director of Health Services), and Staff 31 (Administrator) on 08/14/25 at 12:00 pm. They acknowledged the findings.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by:

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to: On 12/18/24, fire and life safety records dated 06/2024 through 11/2024 were reviewed and revealed the following: * The facility provided no documented evidence staff were provided fire and life safety training on alternate months from fire drills. On 12/19/24 at 4:27 pm, the need to provide fire and life safety instruction to staff on alternating months from fire drills was discussed with Staff 1 (ED) and Staff 4 (Regional Director of Health Services). They acknowledged the findings.

1. Maintenance Director and Executive Director will be educated on regulation by the Regional DIrector of Operations/Regional Environmental person. 2. Maintenance Director/designee will conduct fire drills and staff education per policy and regulation. 2. Documentation will be maintained in TELS system by the Maintenance Director/designee. 3. The results of this will be discussed at the monthly continuous quality improvement meeting. 4. ED will ensure corrections are completed and monitored.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by:

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents were instructed on general safety procedures, evacuation methods, responsibilities during a fire, and designated meeting places inside or outside the building in the event of an actual fire within 24 hours of admission. Findings include, but are not limited to: Fire and life safety records were requested and reviewed with Staff 7 (Maintenance Director) on 12/18/24 and the following deficiency was identified: * There was no documented evidence residents were instructed on general safety procedures, evacuation methods, responsibilities during a fire, and designated meeting places inside or outside the building in the event of an actual fire within 24 hours of admission. The need to ensure residents received fire and life safety instruction within 24 hours of admission was discussed with Staff 1 (ED) and Staff 4 (Regional Director of Health Services) on 12/19/24 at 4:27 pm. They acknowledged the findings.

1. The Maintenance Director and Executive Director will be educated on resident fire safety training requirements by the Regional Director of Operations/Regional Environmental person. 2. The ED/Designee will audit all resident files to ensure the fire training is completed within 24 hours of move in. 3.The ED/Designee will have resident fire safety training in the move in packet to complete within 24 hours of move in. 4. The ED/designee will review new move in files within 24 hours to verify the training has been done.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by:

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by:

ED/Designee will educate all staff on this plan of correction. ED/Designee complete and provide ongoing compliance training related to individualized resident service plans, abuse recognition and reporting, change condition both long and short term. ED/Designee will audit and update resident individualized life story with continued education to staff on implementation of life story focused activity. ED/Designee will audit Plan of Correction tasks to maintain compliance.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure the plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to: Refer to: C160, C260, C280, and C362.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by:

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to keep all interior and exterior materials and surfaces clean and in good repair. Findings include, but are not limited to: Observations of the facility’s three cottages (Alpine, Beachwood and Ponderosa) from 12/17/24 through 12/19/24 revealed the following needed cleaning and/or repair: a. Interior of facility cottages: * Multiple corner guards had cracked/missing pieces (all three cottages); * Dining room window trim had gouges/exposed drywall and missing/discolored paint (Alpine); * Multiple walls, doors, and door frames had scrapes, dings and chips; (Alpine and Beachwood); and * Multiple ceiling light fixtures had lights out. (Alpine). b. Laundry rooms: * Multiple walls had spatters/drips/gouges/exposed drywall and missing and/or peeling paint (all three cottages); * Washing machines had peeling paint on the exterior of the machine and/or interior of the lid (all three cottages); * Build-up/drips of laundry detergent on the exterior of washing machines and pooling on the floor (all three cottages); * Flooring had areas that were cracked/buckled and/or dark discoloration of laminate (all three cottages); * Debris on flooring and on interior of washing machine lids and detergent dispensers (all three cottages); * Ceiling lighting fixtures had lights out and/or were missing covers (all three cottages); * Door gouged with exposed wood (Alpine); and * Hopper had missing faucet handle and was out of order (Beachwood). c. Exterior of facility cottages: * Multiple areas of gutters and downspouts had leaking and pooling of rainwater (all three cottages); * Multiple areas had missing/worn/discolored paint and/or exposed wood (all three cottages); and * Seams on porch drywall had cracks (Alpine). The facility was toured with Staff 1 (ED) and Staff 7 (Maintenance Director) on 12/19/24 at 11:00 am. They acknowledged the areas needing cleaning and/or repair.

1. Maintenance Director and Executive Director will be educated on the CBC environmental walk through by the Regional Environmental person/Regional Director of Operations. 2. Maintenance Director/designee will repair areas identified in walkthrough and will ensure cleanliness 3. Executice Director and/or Maintenance Director will conduct CBC walkthrough once a week x 2 months, 2x's/month x 2 months and then monthly. 4. ED will ensure the corrections are completed and monitored.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by:

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure resident’s rights of privacy and dignity for 1 of 3 sampled residents (#3), who required assistance with ADL care. Findings include, but are not limited to: Resident 3 was subjected to repeated undignified treatment during incontinence care and bed mobility including abrupt handling and movements, lack of communication of what was going on, and poor positioning in the bed which caused the resident visible distress. Refer to C 200.

Refer to C200

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. This Rule is not met as evidenced by:

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the individual and only appropriate staff had a key to access their unit for multiple sampled and unsampled residents. Findings include, but are not limited to: During an interview on 12/18/24 at 10:05 am, Staff 1 (ED) confirmed the majority of the residents did not have keys to their units. The need to ensure the individual and only appropriate staff had a key to access their unit was discussed with Staff 1 and Staff 4 (Regional Director of Health Services) on 12/19/24 at 2:55 pm. They acknowledged the findings.

1. The Regional Director of Operations will educate the Maintenance Director and Executive Director on keys being accessible to the residents. 2. Maintenance Director will obtain apartment specific keys. 3. A monthly audit will be conducted by the ED and/or Maintenance Director to verify keys remain accessible. 4. The results of the monthly audits will be reported to the monthly continuous quality improvement meeting.

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by:

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C150, C160, C200, C231, C295, C362, C420, C422, and C513.

Refer to C150, C160, C200, C231, C295, C362, C420, C422, and C513

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are limited to: Refer to C160, C231 and C362.

Refer to C160, C231, C362,

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to: C160 and C362.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by:

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to: C260, C270, C280 and C340.

Refer to: C260, C270, C280 and C340.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure health service were consistently provided. This is a repeat citation. Findings include, but are not limited to: Refer to C260, C270, and C280.

Refer to C 260, C270 and C280

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to: C260 and C280.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by:

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was documented in the resident's service plan for 2 of 4 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to. Resident’s 1 and 2’s current service plans were reviewed during survey. Each service plan lacked information and/or staff instructions related to the individualized nutrition and hydration status and preferences of the resident. The need to document an individualized nutrition and hydration plan in each resident’s service plan was discussed with Staff 1 (ED), Staff 2 (Health Services Director) and Staff 4 (Regional Director of Health Services.) on 12/19/24. They acknowledged the findings.

1. Resident #1 and #2: The service plan was updated with an individualized nutrition and hydration plan by ED on 1/9/25. 2. ED, RCC'S,HSD and DSD received additional training on the Service Plan policy and procedure by the Regional Director of Health Services; 3. Nutrition and hydration plans for residents will be reviewed prior to move in, quarterly, and with any change of condition and updated accordingly by the HSD/designee. 4. ED/HSD/designee will audit 10% Memory Care resident service plans x 3 months for nutrition/hydration plans and report to the continuous quality improvement meeting.

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills. This Rule is not met as evidenced by:

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to develop individualized activity plans for 4 of 5 sampled residents (#s 1, 3, 4 and 7) whose activity plans were reviewed. Findings include, but are not limited to: Residents 1, 3, 4, and 7’s records were reviewed during the survey. There was no resident specific activity plan which detailed what, when, how and how often staff should offer and assist each resident with individualized activities. The need to develop individualized activity plans, for each memory care resident was discussed with Staff 1 (ED), Staff 2 (Health Services Director) and Staff 4 (Regional Director of Health Services) on 12/19/24. They acknowledged the findings.

1. Resident(s) # 1, 3, 4, 7: The service plan was updated with an individualized activity plan by RCC, HSD and ED by 1/17/2025 2. ED/Resident Experience Director received additional training on Life Story Engagement Evaluation & Individualized Activity Plan by the Regional Director of Health Services. 3. Activity plans for residents will be reviewed prior to move in, quarterly, and with any change of condition and updated accordingly by the HSD/designee. 4. ED/HSD/designee will audit 10% Memory Care resident service plans x 3 months for activity plans and report to the continuous quality improvement meeting.

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to develop individualized activity plans for 3 of 3 sampled residents (#s 8, 9, and 10) whose activity plans were reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 8, 9, and 10’s records were reviewed during the survey. There was no resident specific activity plan which detailed what, when, how and how often staff should offer and assist each resident with individualized activities. The need to develop individualized activity plans for each memory care resident was discussed with Staff 1 (ED) on 05/07/25. She acknowledged the findings.

The ED and HSD will be educated on individualized activity plans by the Regional Director of Health Services. The HSD/Designee will update resident 8, 9 and 10 activity plans. The ED/Designee to audit all individualized activity plans to ensure that resident activity plans encompassing social, emotional, physical, spiritual interests and abilities. After initial audit, the ED/Designee will audit 10% of resident individualized activity plans x 3 months to make sure changes are captured and services reflect current need.

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: