Print Inspection: CHOW010562

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 short-term changes of condition were monitored weekly through resolution, with interventions communicated to staff on all shifts, for 1 of 1 sampled resident (#1) who experienced a change of condition. Findings include, but are not limited to: Resident 1 was admitted to the in 10/2024 with diagnoses including heart failure and dementia. A review of Resident 1's clinical record, from 01/06/26 through 04/06/26, revealed the following: * 01/16/26 – Staff documented the resident’s “left groin is extremely red and smelly – very characteristic of a yeast infection”; * 02/10/26 – Staff found the resident on the floor, and the resident stated they had fallen; and * 03/01/26 – Staff documented the resident was experiencing a rash to their groin area. There was no documented evidence of resident-specific instructions or interventions communicated to staff on all shifts, with weekly monitoring through resolution. On 04/08/26 at approximately 11:00 am, Staff 1 (Administrator) and Staff 2 (Owner/RDO), confirmed there was no documented evidence actions or interventions were determined and communicated to staff on all shifts, with weekly monitoring through resolution. On 04/08/26, the need to ensure residents who experienced a change of condition were monitored weekly through resolution, with documented evidence of instruction or interventions communicated staff on all shifts, was discussed with Staff 1 and Staff 2. They acknowledged the findings.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring 1) RN completed assessment of resident # 1, RN implemented monitoring and provider was notified of skin concern. 24 hour page was updated to improve communication and continuity of care. 2)Administrator/designee and Community RN will be provided training regarding resident changes of condition. Training will include, what a short term and Significant change of condition is, the process of addressing changes including; implementing a Temporary service plan to communicate with staff, resident specific instructions/interventions, weekly monitoring notes, and resolution for the change of condition. Community RN will go back and re-complete Modules from NurseLearn on changes of condition. 3)The system will be reviewed daily to ensure compliance is maintained through review of daily notes, EMR reports, monitoring reports, as well as weekly in clinical meetings, and monthly using Administrator Quality Assurance Audit. 4)The Administrator and/or designee and Registered Nurse will be respsonsible to ensure the corrections are completed and monitored, with oversight from Compliance Director.

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 411-054-0090 (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 the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire drill records reviewed from 10/2025 through 03/2026 lacked documented evidence fire drills and fire life safety trainings for staff were being conducted every other month on alternating shifts. On 04/07/26 at approximately 2:30 pm, the need to ensure fire life safety training and drills were being conducted on alternating months was discussed with Staff 1 (Administrator). She acknowledged the findings.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety 1) Life safety training was completed on 4/10/26. Fire Drills will be conducted and recorded at a minimum of every other month at different times of the day, evening, and night shift. Fire and Life Safety Training will be provided on alternating months. 2) Review of fire drills, Life safety requirements and processes according to OARs will be completed with staff, and the Administrator/Designee. 3) The system will be evaluated to ensure all requirements have been met and documented using the Monthly Administrator Quality Assurance audit. 4) The Administrator/Designee and Maintenance Director will be responsible to ensure the corrections are completed/monitored with oversight from Compliance Director.

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: