Print Inspection: CHOW006175

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 provided clear directions to staff regarding the delivery of services for 5 of 6 sampled residents (#s 1, 2, 3, 4, and 6) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 04/2024 with diagnoses including Alzheimer’s disease, schizoaffective disorder, nicotine dependence, and incontinence of bowel and bladder. Observations were made of the resident's care on 08/18/25 and 08/19/25, interviews with the resident and facility staff were conducted, and the service plan, dated 08/06/25, was reviewed. Resident 3's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Number of staff needed to assist with ADLs including dressing/undressing; * Instructions on signs and symptoms of depression to report while on anti-depressant therapy; * Instructions on signs and symptoms of schizoaffective disorder to report while on anti-psychotic therapy; * Clear instructions to staff on how to provide care to someone who has a sling related to upper extremity fracture; * Preference for female care staff to provide ADLs; * How a person expresses memory loss; and * Clear instructions to staff when the resident smoked cigarettes and marijuana. Staff 10 (MT/CG) was interviewed on 08/19/25 at 12:04 pm and stated Resident 3 was independent with ADLs prior to the fall on 08/05/25, which resulted in a left upper arm fracture. After the fall, the resident required one person assist with “all ADLs, especially dressing/undressing… and toileting sometimes.” During the interview with the resident on 08/19/25 at 2:33 pm, s/he confirmed the need for one person assist with ADLs and stated, “I am one handed now... and very private about bathroom. Use my right hand to help [with toileting] and prefer female.” Review of the MARs confirmed the resident was taking Wellbutrin (for depression) daily and Risperdal (for schizophrenia). During the interview with the resident on 08/19/25, a full bottle with nuggets of marijuana and several pipes were noted on the table next to the resident. Additionally, a strong odor of marijuana was present in the room. The need to ensure service plans reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (Assistant Administrator), Staff 2 (MCC Administrator), and Staff 15 (Regional Director of Operations) on 08/21/25 at 2:25 pm. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 05/2022 with diagnoses including anxiety, depression, tremors, hearing loss, dementia, and carpal tunnel syndrome. Observations were made of the resident's care on 08/20/25 and 08/21/25, interviews with the resident and facility staff were conducted, and the service plan, dated 08/08/25, was reviewed. Resident 4's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Number of staff needed to assist with ADLs including dressing/undressing; * Instructions on signs and symptoms of depression to report while on anti-depressant therapy; * Instructions to staff on assisting with hearing aids as needed; * Instructions when resident partially self-administers medications; * Incorrect reference to resident using bed side cane; * Incorrect reference to resident liquid intake consistency; * Instructions to staff on providing care to the resident with body tremors; and * Electric wheelchair equipment precautions and instructions for proper maintenance. The resident stated on 08/20/25 at 4:50 pm the order for soft mechanical texture was given because the resident had no upper dentures and requested the change of texture for easy chewing. The resident denied experiencing difficulties swallowing. During the interview on 08/21/25 at 12:14 pm, Staff 7 (MT) stated the resident was getting soft mechanical texture meals and thin liquids, not thickened liquids as noted in the service plan. The resident was noted in the service plan to be independent with hearing aids; however, on 08/21/25, Staff 7 was observed placing hearing aids in Resident 4’s ears bilaterally due to the resident hand’s tremors. During the interview on 08/20/25, the resident confirmed s/he was taking over-the-counter medications that were not listed on the MAR, including melatonin gummies (for sleep), arthritis pain gel (for pain), and Salonpas patch (for pain). The need to ensure service plans reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (Assistant Administrator), Staff 2 (MCC Administrator), and Staff 15 (Regional Director of Operations) on 08/21/25 at 2:25 pm. They acknowledged the findings. 3. Resident 1 was admitted to the facility in 01/2022 with diagnoses including lymphedema, congestive heart failure and blindness. Observations of the resident, interviews with staff, review of interim service plans, observation notes from 05/28/25 through 08/19/25, and review of the service plan, dated 06/30/25, 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: * Preference for female assistance with ADL cares; * Pain, including the location and non-drug interventions; * Who managed the portable oxygen unit; * How staff alert they have entered the apartment by blinking lights; and * Assistance needed for bed mobility. In an interview on 08/21/25 at 11:50 am, Staff 16 (CG) entered Resident 2’s apartment and observed Staff 16 turn the lights on and off prior to approaching the resident. He noted, “We do this because [Resident 1] can’t see or hear so we don’t want to startle [him/her].” Staff 16 also indicated Resident 1 only wanted female staff assisting with toileting and dressing. In an interview on 08/21/25 at 1:00 pm, Resident 1 indicated s/he needed staff’s assistance to get out of bed and noted s/he experienced pain in the ankles and knees. The need to ensure resident service plans were reflective of current care needs and/or provided clear direction to staff was discussed with Staff 1 (Assistant Administrator) and Staff 2 (MCC Administrator), and Staff 15 (Regional Director of Operations) on 08/21/25 at 3:15 pm. They acknowledged the findings. 4. Resident 2 was admitted to the facility in 06/2021 with diagnoses including stroke. Interviews with staff, review of interim service plans, observation notes from 05/27/25 through 08/12/25, and review of the service plan, dated 06/18/25, 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: * Preference for female assistance with ADL cares; * Pain, including the location and non-drug interventions; and * Outside providers, including HH RN and PT services being provided. In an interview on 08/21/25 at 11:30 am, Staff 16 (CG) indicated Resident 2 preferred female staff to assist him/her with showers and dressing. Resident 2 allowed male staff to assist with toileting on occasion, if s/he was in a hurry and no one else was available. The need to ensure resident service plans were reflective of current care needs and/or provided clear direction to staff was discussed with Staff 1 (Assistant Administrator), Staff 2 (MCC Administrator), and Staff 15 (Regional Director of Operations) on 08/21/25 at 3:15 pm. They acknowledged the findings. 5. Resident 6 moved into the facility in 11/2021 with diagnoses including diabetes and had recently been admitted onto hospice services. The resident’s service plan, dated 08/06/25, was reviewed, and Resident 6 was interviewed. The service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Daily vitals; * Resident-centered fall interventions; * Assistance needed with ADLs; * Preferences of where s/he ate his/her meals; * Frequency of safety checks; * Transportation needs; * The use of siderails, what to monitor the siderails for, and who to report to if there was a malfunction; and * Services hospice provided, including which disciplines and what days of the week the services are provided. Resident 6 was interviewed on 08/21/25 at 11:02 am. Observations were made of bilateral siderails secured to a hospital bed in the raised position. The resident voiced frustration of not knowing when the hospice bath aide would be at the facility and was told “Tuesdays and Thursday or Friday.” Resident 6 confirmed the bath aide “never came.” The resident also stated not going to the dining room for his/her meals. Two health events occurred in the dining room which were embarrassing to Resident 6. At that time, the resident chose to eat in his/her apartment to avoid any future embarrassment. The need to ensure service plans reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (Assistant Administrator), Staff 2 (MCC Administrator), and Staff 15 (Regional Director of Operations) on 08/21/25 at 1:08 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 observation, interview, and record review, it was determined the facility failed to evaluate the resident, refer to the facility nurse, document the change, and/or update the service plan as needed for a significant change of condition, and failed to determine what action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff, document progress until the condition resolved and monitor each resident consistent with his or her evaluated needs for 4 of 6 sampled residents (#s 1, 2, 3, and 4) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 06/2021 with diagnoses including stroke. A review of the resident’s clinical record indicated the following: On 06/09/25, staff documented the resident was admitted to the hospital for a stroke. Hospital discharge notes indicated the resident had ongoing weakness and difficulty ambulating. Resident 2 returned from the hospital on 06/11/25. There was no documented evidence the resident was evaluated for the weakness and difficulty ambulating upon return from the hospital. Resident 2 experienced a stroke and subsequent decline in ADL function, which constituted a significant change of condition which required the facility to evaluate the resident, document the change, and update the service plan as needed. In an interview on 08/20/25 at 2:15 pm, Staff 2 (MCC Administrator) acknowledged an evaluation for the significant change of condition was not completed upon Resident 2’s return from the hospital. She further acknowledged the change was not documented, and the service plan was not updated as needed. b. On 07/17/25, an observation note was completed by Staff 3 for a significant change of condition and indicated “RN assessed [Resident 2] at the hospital this morning for potential return home” following a compression fracture and weakness. Upon return to the facility, there was no documented evidence the resident was evaluated, the change was documented, and the service plan was updated as needed regarding pain, including pharmaceutical and non-pharmaceutical interventions. The need to ensure the facility evaluated significant changes of condition, the change was documented, and the service plan was updated as needed was discussed Staff 1 (Assistant Administrator), Staff 2, and Staff 15 (Regional Director of Operations) on 08/21/25 at 3:15 pm. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 01/2022 with diagnoses including lymphedema, congestive heart failure and blindness. a. Facility weight records for Resident 1 noted the following: * 07/01/25: 195 pounds; and * 08/01/25: 182.6 pounds. Between 07/01/25 and 08/01/25, Resident 1 experienced weight loss of 12.4 pounds, or 6.4% of his/her total body weight, in one month. This constituted a severe weight loss and was a significant change of condition. The service plan indicated Resident 1 was weighed daily and “to monitor [his/her] weight gain or loss, Staff is to report to the RN and PCP if there is any significant change in [Resident 2’s] weight.” On 08/19/25 at 4:30 pm, Staff 3 (RN) stated she was not notified of Resident 1’s significant weight loss and she was not aware of a system in place to notify the RN when there was a significant weight loss or gain. The facility lacked documented evidence Resident 1 was referred to the facility RN regarding his/her 6.4% total body weight loss in one month. b. A review of the resident’s clinical record revealed the following: * On 07/09/25 the resident returned from an appointment and his/her Tramadol 50 mg dose was increased to 1 tablet every 8 hours PRN pain. There was no documented evidence the resident had been monitored through resolution as to whether the pain control measures were effective and any adverse effects from the opioid pain medication, such as constipation. * On 07/24/25 the resident started a new prescription for Singulair 10 mg daily for asthma. There was no documented evidence the resident had been monitored through resolution as to whether the medication was effective and any adverse effects. * On 08/01/25 staff documented the resident “has been having increased weakness and is needing two people for assist.” There was no documented evidence the resident had been evaluated to determine what actions or intervention was needed, communicated the determined action or intervention to staff, and monitored at least weekly through resolution for the weakness and need for increased assistance. The need to ensure the facility referred significant changes of condition to the facility RN, determined, documented, and communicated determined actions or interventions to staff, and monitored conditions with documented progress at least weekly, until short-term changes of condition were resolved was discussed with Staff 1 (Assistant Administrator), Staff 2 (MCC Administrator), and Staff 15 (Regional Director of Operations) on 08/21/25 at 3:15 pm. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 04/2024 with diagnoses including Alzheimer’s disease, schizoaffective disorder, nicotine dependence, and incontinence of bowel and bladder. A review of Resident 3’s clinical records, 05/27/25 through 08/18/25, including the current service plan, dated 08/06/25, showed the following: * On 08/06/25, the resident returned to the facility after an emergency room visit related to a fracture of [his/her] left upper arm secondary to an unwitnessed fall. The resident was started on hydrocodone-acetaminophen 5-325 mg starter pack (opioid pain reliever) to control pain in the left upper arm. There was no documented evidence the resident had been monitored through resolution as to whether the pain control measures were effective. * On 08/07/25, the resident returned to the facility after an emergency room visit related to confusion secondary to a bladder infection. On 08/08/25, the resident was started on cephalexin 500 mg (antibiotic) to control infection. There was no documented evidence the resident had been monitored through resolution for signs and symptoms of bladder infection, effectiveness and adverse effects of the antibiotic, and level of cognition and confusion. * On 08/09/25, the resident returned to the facility after an emergency room visit related to increased pain of the left upper extremity. On 08/09/25, the resident was started on hydrocodone-acetaminophen 5-325 mg starter pack to control pain. There was no documented evidence the resident had been monitored through resolution as to whether the pain control measures were effective. * On 08/13/25, the resident was started on Bactrim (antibiotic). There was no documented evidence the resident had been monitored through resolution for signs and symptoms of bladder infection, and effectiveness and adverse effects of the antibiotic. The need to ensure the facility had a system in place to monitor each resident consistent with his or her evaluated needs and service plan was reviewed with Staff 1 (Assistant Administrator), Staff 2 (MC Administrator), and Staff 15 (Regional Director of Operations) on 08/21/25 at 2:25 pm. They acknowledged the findings. 4. Resident 4 was admitted to the facility in 05/2022 with diagnoses including anxiety, depression, tremors, hearing loss, dementia, and carpal tunnel syndrome. A review of Resident 4’s clinical records, 05/18/25 through 08/12/25, including the current service plan, dated 08/08/25, showed the following: * On 06/02/25, the resident discontinued propranolol 10 mg (for blood pressure). There was no documented evidence the resident was monitored for adverse effects of discontinuing the medication, such as high blood pressure. * On 06/03/25, an observation note recorded, “Resident called for assistance after running over [his/her] right foot with [his/her] electric wheelchair. Resident has slight bruising on [his/her] right foot.” There was no documented evidence the facility evaluated the extent of the injury on the resident’s right foot or monitored the bruising through resolution of the condition. * On 07/28/25, the resident had an unwitnessed fall with abrasions to both knees. There was no documented evidence the facility monitored the resident for signs and symptoms of complications to the abrasions, such as infection. The need to ensure the facility had a system in place to monitor each resident consistent with his or her evaluated needs and service plan and to monitor short-term changes of condition with weekly progress noted to resolution was reviewed with Staff 1 (Assistant Administrator), Staff 2 (MC Administrator), and Staff 15 (Regional Director of Operations) on 08/21/25 at 2:25 pm. They acknowledged the findings.

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 a timely RN assessment was completed that included findings, resident status, and interventions made as a result of the assessment for 1 of 3 sampled residents (#2) who experienced significant changes of condition. Findings include, but are not limited to: Resident 2 was admitted to the facility in 06/2021 with diagnoses including stroke. a. On 06/09/25, staff documented the resident was admitted to the hospital for a stroke. Resident 2 returned from the hospital on 06/11/25 and hospital discharge notes indicated the resident had ongoing weakness and difficulty ambulating. The stroke constituted a significant change of condition requiring a facility RN assessment. There was no documented evidence a timely RN assessment was completed when Resident 2 returned to the facility. In an interview on 08/19/25 at 4:30 pm, Staff 3 (RN) acknowledged an RN assessment was not completed until 06/18/25, seven days after the significant change of condition occurred. b. On 07/17/25, staff documented the resident experienced a hospital stay for a compression fracture of the lumbar spine. Review of the RN assessment completed on 07/17/25 revealed no interventions were made as a result of the assessment for the compression fracture related to pain, including pharmaceutical and non-pharmaceutical interventions. The need to ensure a timely RN assessment was completed which documented findings, resident status, and interventions made as a result of the assessment for all significant changes of condition was discussed with Staff 1 (Assistant Administrator), Staff 2 (MCC Administrator), and Staff 15 (Regional Director of Operations) on 08/21/25 at 3:15 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 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to coordinate off-site health services for residents who could not or chose not to self-manage their health services including making adjustments to the residents’ services and service plans for 4 of 4 sampled residents (#s 2, 3, 4, and 6) whose records were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 04/2024 with diagnoses including Alzheimer’s disease, schizoaffective disorder, nicotine dependence, and incontinence of bowel and bladder. The resident’s clinical records, including the service plan dated 08/06/25, observation notes, dated 05/27/25 through 08/18/25, and outside provider notes were reviewed and revealed the following: * Patient discharge instructions from an emergency room visit on 08/07/25 stated, “[Resident] has a UTI [urinary tract infection]. Also [his/her] alcohol level was 47.” The communication instructed the resident “Refrain from drinking alcohol with pain medications”; and * Patient discharge instructions from an emergency room visit on 08/09/25 stated, “…recommend taking MiraLax (laxative) once or twice a day to prevent constipation.” There was no documented evidence the resident’s service plan was adjusted to incorporate outside provider recommendations. During an interview on 08/19/25 at 12:04 pm, Staff 10 (MT/CG) confirmed the resident received daily doses of opioid pain reliever from 08/06/25 through 08/15/25 to control pain related to an upper left extremity fracture and no laxative was administered per patient discharge instructions. The need to ensure the facility coordinated off-site health services for residents who could not or chose not to self-manage their health services including making adjustments to the resident’s services and service plans was reviewed with Staff 1 (Assistant Administrator), Staff 2 (MCC Administrator), and Staff 15 (Regional Director of Operations) on 08/21/25 at 2:25 pm. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 05/2022 with diagnoses including anxiety, depression, tremors, hearing loss, dementia, and carpal tunnel syndrome. The resident’s clinical records, including the service plan dated 08/08/25, Observation notes, dated 05/18/25 through 08/12/25, current MAR, and Outside Provider notes were reviewed. A “Pharmacist’s Recommendation to Prescriber,” dated and signed 06/30/25, recommended to taper omeprazole 20mg (to treat heartburn and conditions caused by too much acid in the stomach) over two to four weeks and monitor for rebound of dyspepsia after stopping. The recommendation noted the long-term use of omeprazole “should be minimized whenever possible.” There was no documented evidence the facility staff updated the resident’s service plan to incorporate the pharmacist’s recommendation, and the resident’s MAR indicated the facility staff continued to administer omeprazole. The need to ensure the facility coordinated off-site health services for residents who cannot or choose not to self-manage their health services including making adjustments to the resident’s services and service plans was reviewed with Staff 1 (Assistant Administrator), Staff 2 (MCC Administrator), and Staff 15 (Regional Director of Operations) on 08/21/25 at 2:25 pm. They acknowledged the findings. 3. Resident 2 was admitted to the facility in 06/2021 with diagnoses including stroke. Observation notes, dated 05/27/25 through 08/12/25, outside agency services notes, dated 06/12/25 to 08/08/25, interim service plans, and the service plan, dated 06/18/25, were reviewed, and interviews with the resident and staff were conducted. There was no documented evidence staff were informed of the new instructions and the service plan was updated with the following recommendations: * 06/12/25: HH nurse note indicated, “Encourage high-protein diet, Frequent repositioning, Encourage wiggling toes/ankle pumps…”; * 07/18/25: HH PT note stated, “Please assist/remind HEP (home exercise program) on [sic] Bed…” * 07/21/25: HH nurse note indicated, “Please check B/P (blood pressure) prn dizziness, whooshing in ears, nose bleeds, change in vision or headache. Please monitor BM (bowel movement) daily…”; * 07/22/25: HH PT note instructions included, “Use walker to transfer to/from chairs…toilet transfers, Hold grab bar to stand, then let go left hand on wheelchair to keep back straight and not twist.”; * 07/30/25: HH nurse note regarding high blood pressure: “Call [Home Health Agency] if Pt (patient) experiences any Headaches, Dizziness, SOB (shortness of breath), chest pain or visual changes”; * 07/30/25: HH PT note instructed, “Staff to accompany [him/her] walking to all meals. May ride back if really needed. Keep backed up to toilet and chair’s. No twisting or bending.”; * 08/01/25: HH PT note indicated, “Encourage sit in recliner to increase strength and cont (continue) walking”; * 08/06/25: HH nurse note indicated, “Please enc (encourage) fluids and snacks”; and * 08/07/25: HH PT note indicated, “Help [him/her] with transfers and walking.” In an interview on 08/20/25 at 2:15 pm with Staff 2 (MCC Administrator), she acknowledged there was no documented evidence Resident 2’s service plan was adjusted to incorporate outside provider recommendations. The need to ensure staff were informed of new interventions and the service plan adjusted as necessary after on-site health services were provided was discussed with Staff 1 (Assistant Administrator), Staff 2, and Staff 15 (Regional Director of Operations) on 08/21/25 at 3:15 pm. They acknowledged the findings. 4. Resident 6 moved into the facility in 11/2011 with diagnoses including stroke and chronic obstructive pulmonary disease. The resident’s clinical records, including the service plan, dated 08/06/25, observation notes, dated 05/19/25 through 08/14/25, and outside provider visit notes, dated 07/08/25 through 08/18/25, were reviewed and revealed the following: * 07/16/25: The facility RN documented, "If [Resident 6] was to have another episode of stroke symptoms hospital provider made recommendation for [the resident] to lay in bed with legs elevated for 30 [plus] minutes to see if [his/her] symptoms resolve"; * 07/18/25: HHPT recommended staff to "help [him/her]" as "[his/her] arms pull on [his/her] neck and cause blood flow issues"; * 07/22/25: HHOT recommended staff to "encourage [Resident 6] to go to activities"; * 07/31/25: HHRN recommended staff to "encourage [the resident] to hydrate and implement protein rich foods"; and * 08/01/25: HHPT documented that the resident's physician "approved use of heat pad for pain relief." There was no documented evidence Resident 6’s service plan was adjusted to incorporate outside provider recommendations. The need to ensure the facility coordinated off-site health services for residents who cannot or choose not to self-manage their health services including making adjustments to the resident’s services and service plans was reviewed with Staff 1 (Assistant Administrator), Staff 2 (MCC Administrator), and Staff 15 (Regional Director of Operations) on 08/21/25 at 1:08 pm. They acknowledged the findings.

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

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 4 of 6 sampled residents (#s 1, 2, 4, and 6) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 05/2022 with diagnoses including anxiety, depression, tremors, hearing loss, dementia, and carpal tunnel syndrome. Resident 4’s current facility records included a physician order to “Obtain [blood pressure twice daily]. Notify [Primary Care Physician]/RN if top number above 150 or bottom number above 90, top number below 90 or bottom number below 60.” Review of MARs showed the bottom number of Resident 4’s blood pressure was below 60 on five occasions in June, eight occasions in July and nine occasions in August. During an interview on 08/21/25 at 12:14 pm, Staff 7 (MT) stated the facility notified the PCP of blood pressure outside the specified parameters by fax. However, there was no documented evidence the facility notified the PCP. The need to ensure treatment orders were carried out as prescribed was reviewed with Staff 1 (Assistant Administrator), Staff 2 (MCC Administrator), and Staff 15 (Regional Director of Operations) on 08/21/25 at 2:25 pm. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 01/2022 with diagnoses including lymphedema, congestive heart failure, and blindness. The resident's 08/01/25 to 08/19/25 MAR and physician orders, dated 06/04/25, were reviewed. The following was identified: Resident 1’s current facility records included a physician order to “Obtain BP [blood pressure] daily. Notify PCP [Primary Care Physician]/RN if top number above 150 or bottom number above 90, top number below 90 or bottom number below 60.” Review of the MAR showed the bottom number of Resident 1’s blood pressure was taken twice daily and was documented below 60 on 16 occasions. There was no documented evidence the facility notified the physician when the bottom number for his/her blood pressure was below 60. The need to ensure treatment orders were carried out as prescribed was discussed with Staff 1 (Assistant Administrator), Staff 2 (MCC Administrator), and Staff 15 (Regional Director of Operations) on 08/21/25 at 3:15 pm. They acknowledged the findings. No further information was provided. 3. Resident 2 was admitted to the facility in 06/2021 with diagnoses including stroke and osteoarthritis of knee. The resident's 08/01/25 to 08/19/25 MAR, physician orders, dated 06/22/25, and weights, dated 02/05/25 through 08/13/25, were reviewed. The following was identified: A physician’s order to “Obtain weight weekly” had been initiated on 03/29/24. The Vitals History weight records for Resident 2 were reviewed, and the following weights were documented on: * 06/04/25; * 07/02/25; * 08/06/25; and * 08/13/25. There were no weekly weights documented for the following dates: 06/11/25, 06/18/25, 06/25/25, 07/09/25, 07/16/25, 07/23/25, and 07/30/25. The need to ensure treatment orders were carried out as prescribed was discussed with Staff 1 (Assistant Administrator), Staff 2 (MCC Administrator), and Staff 15 (Regional Director of Operations) on 08/21/25 at 3:15 pm. They acknowledged the findings. No further information was provided. 4. Resident 6 moved into the facility in 11/2011 with diagnoses including chronic pain. Resident 6's 08/01/25 through 08/21/25 MAR and physician's orders were reviewed. The following was noted: The resident was on a scheduled dose of Miralax (for constipation) and had PRN orders for two additional constipation medications - Milk of Magnesia and lactulose. Resident 6 was newly admitted onto hospice services and had two PRN narcotics available when s/he was experiencing pain. Side effects listed for the PRN narcotic included constipation. On 08/08/25, a signed physician's order was faxed to the facility instructing staff to "Continue to monitor and record bowel movements." There was no documented evidence the facility was following the prescriber's orders to monitor and record the resident’s bowel movements. The need to ensure physician’s orders were carried out as prescribed was reviewed with Staff 1 (Assistant Administrator), Staff 2 (MCC Administrator), and Staff 15 (Regional Director of Operations) on 08/21/25 at 1:08 pm. They acknowledged the findings.

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

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure resident-specific parameters and instructions for PRN medications were included on the MAR for 2 of 6 sampled residents (#s 1 and 6) whose medications were reviewed. Findings include, but are not limited to: 1. Resident 6 moved into the facility with diagnoses including chronic pain. The resident’s 08/01/25 through 08/18/25 MAR and physician’s orders were reviewed. The following PRN medications did not direct staff on the sequential order of administration: * Hydrocodone (for pain); * Morphine (for pain); * Milk of Magnesia (for constipation); and * Lactulose (for constipation). The need for MARs to be accurate and ensure resident-specific parameters and instructions for PRN medications was reviewed with Staff 1 (Assistant Administrator), Staff 2 (MCC Administrator), and Staff 15 (Regional Director of Operations) on 08/21/25 at 1:08 pm. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 01/2022 with diagnoses including lymphedema, congestive heart failure, and blindness. The resident's 08/01/25 to 08/19/25 MAR and physician orders, dated 06/25/25, were reviewed. The following was identified: Resident 1’s current facility records included a physician order to “Obtain [oxygen] readings twice daily”. The MAR lacked resident-specific parameters to indicate when staff needed to notify the prescriber or nurse. In an interview on 08/21/25 at 11:30 am, Staff 2 (MCC Administrator) acknowledged the resident-specific parameters, related to oxygen saturation readings, were needed. The need to ensure MARs included any resident-specific instructions including when to call the prescriber or nurse was discussed with Staff 1 (Assistant Administrator), Staff 2, and Staff 15 (Regional Director of Operations) on 08/21/25. They acknowledged the findings.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by:

OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure there was a physician's or other legally recognized practitioner's written order of approval for self-administration of a prescription medication for 1 of 1 sampled resident (#6) who was reviewed for self-administration of insulin. Findings include, but are not limited to: Resident 6 moved into the facility in 11/2021 with diagnoses including diabetes and a stroke. The resident's clinical record, including the most recent signed physician's orders, dated 08/08/25, a “Medication Self-Administration Evaluation,” dated 06/25/25, and observation notes, dated 05/19/25 through 08/14/25, were reviewed. Resident 6 was observed, and staff were interviewed. The following was identified: On 08/18/25, a “Medication Self-Administration Evaluation” was received. The evaluation, dated 06/25/25, indicated the resident self-administered insulin. On 06/18/25, staff documented the resident had experienced an "altered mental status". During those times, s/he would go "blank" with "increased tremors for a short amount of time". On 07/14/25, staff documented that Resident 6 had been admitted to the hospital with the diagnosis of a "stroke.” On 08/06/25, the resident was admitted onto hospice services and physician's orders were faxed to the facility two days later. There was no indication on the orders of the physician’s approval for Resident 6 to self-administer any medications. On 08/21/25 at 8:15 am, Staff 2 (MCC Administrator) confirmed there was no current signed physician's order for the resident to administer his/her own insulin. On 08/21/25 at 11:02 am, Resident 6 was observed in his/her apartment. The resident stated s/he was in pain and was not able to remain still as, "it just hurts too much.” Resident 6 confirmed monitoring his/her blood sugars and administering his/her insulin, stating "I only do my insulin, [the facility] handles the rest [of the medications]." The need to ensure residents who self-administered their own prescription medications had a signed physician’s or other legally recognized practitioner's order of approval was reviewed with Staff 1 (Assistant Administrator), Staff 2, and Staff 15 (Regional Director of Operations) on 08/21/25 at 1:08 pm. They acknowledged the findings.

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

OAR 411-054-0037 (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 the Acuity Based Staffing Tool (ABST) accurately captured care time and care elements that staff were providing to each resident for 4 of 6 sampled residents (#s 1, 2, 4, and 6) whose ABSTs were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 01/2022 with diagnoses including lymphedema, congestive heart failure, and blindness. Observations and interviews with the resident, interviews with staff, review of the 06/30/25 service plan, and Resident 1’s ABST data was reviewed. The following areas were not reflective of the resident’s current ADL assistance: * Assisting with communication, assistive devices for hearing and vision; * Transferring in and out of bed or chair; * Responding to call lights; and * Safety checks and fall prevention. The need to ensure the ABST addressed the amount of staff time needed to provide care was discussed with Staff 1 (Assistant Administrator), Staff 2 (Memory Care Administrator), and Staff 15 (Regional Director of Operations) on 08/21/25 at 3:15 pm. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 06/2021 with diagnoses including stroke. Observations and interviews with the resident, interviews with staff, review of the 06/18/25 service plan, and Resident 2’s ABST data was reviewed. The following areas were not reflective of the resident’s current ADL assistance: * Escorting to and from meals or activities; * Transferring in and out of bed or chair; * Safety checks and fall prevention; * Bowel and bladder management; and * Dressing and undressing. The need to ensure the ABST addressed the amount of staff time needed to provide care was discussed with Staff 1 (Assistant Administrator), Staff 2 (MCC Administrator), and Staff 15 (Regional Director of Operations) on 08/21/25 at 3:15 pm. They acknowledged the findings. 3. Resident 4 was admitted to the facility in 05/2022 with diagnoses including anxiety, depression, tremors, hearing loss, dementia, and carpal tunnel syndrome. The resident’s ABST, the service plan dated 08/08/25, and interim service plans were reviewed. Observations of the resident were made, and interviews with staff were conducted. The resident’s ABST calculation did not incorporate expected care time in the following areas: * Safety checks, fall prevention; *Assisting with communication, assistive devices for hearing, vision, speech; * Non-drug interventions for pain management; and * Dressing and undressing. he need to ensure the ABST addressed the amount of staff time needed to provide care was reviewed with Staff 1 (Assistant Administrator), Staff 2 (MCC Administrator), and Staff 15 (Regional Director of Operations) on 08/21/25 at 2:25 pm. They acknowledged the findings. 4. Resident 6 moved into the facility in 11/2021 with diagnoses including stroke and had a recent admission onto hospice services. Observations and interviews with the resident, interviews with staff, review of the 08/06/25 service plan, interim service plans, and Resident 6’s ABST data were reviewed. The following areas were not reflective of the time required for ADL assistance in the following areas: * Safety checks; * Supporting while eating; * Transfers; * Bowel and bladder management; and * Dressing and undressing. The need to ensure the ABST addressed the amount of staff time needed to provide care was reviewed with Staff 1 (Assistant Administrator), Staff 2 (MCC Administrator), and Staff 15 (Regional Director of Operations) on 08/21/25 at 1:08 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 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) evaluation was updated and reviewed before a resident moved in and whenever there was a significant change of condition for 3 of 4 sampled residents (#s 2, 5, and 6) whose ABST evaluations were reviewed. Findings include but are not limited to: The facility’s ABST was reviewed during the survey on 08/18/25 through 08/21/25. The following was identified: a. Resident 5 did not have an ABST evaluation completed prior to move-in. b. Residents 2 and 6’s ABST evaluation did not have evidence that it was updated when the residents experienced a significant change of condition. The need to ensure residents’ ABST evaluations were updated before move-in and whenever there was a significant change of condition was discussed with Staff 1 (Assistant Administrator), Staff 2 (MCC Administrator), and Staff 15 (Regional Director of Operations) on 08/21/25 at 1:08 pm. They acknowledged the findings.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by:

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 ensure fire drills were conducted according to Oregon Fire Code (OFC) and fire and life safety instruction was provided to staff on alternate months from fire drills. Findings include, but are not limited to: Six months of facility fire drill and fire and life safety records, dated 02/2025 through 08/2025, were reviewed on 08/20/25 and revealed the following: a. Fire drills lacked documented evidence of the following: * The escape route used; * Evacuation time period needed; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; and * Number of occupants evacuated. b. The facility lacked documented evidence that staff were trained in fire and life safety procedures on alternate months of fire drills. The need to ensure fire drills were conducted per OFC and staff were trained in fire and life safety procedures on alternate months from fire drills was discussed with Staff 1 (Assistant Administrator) and Staff 2 (MCC Administrator) on 8/21/25 at 12:34 pm. They acknowledged the findings.

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 in fire and life safety procedures within 24 hours of admission and at least annually thereafter. Findings include, but are not limited to: Facility fire and life safety records were reviewed on 08/20/25. The facility lacked documented evidence residents were instructed in general safety procedures, evacuation methods, and responsibilities within 24 hours of admission and at least annually. The need to ensure residents were instructed in fire and life safety procedures within 24 hours of admission and at least annually, was discussed with Staff 1 (Assistant Administrator) and Staff 2 (MCC Administrator) on 08/21/25 at 12:34 pm. They acknowledged the findings.

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: