Print Inspection: RL000057

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. Findings include, but are not limited to: Observations were made during the survey and the following was noted: • The carpet throughout the facility was worn out, threadbare, and uneven. Additionally, multiple areas on the carpet were screwed down in the bubbled-up regions, which created a tripping hazard; and • On 08/28/24 approximately 10:30 am, the surveyor observed Room 9’s bathroom. The floor was bulging and bumpy, which could be a tripping hazard. It was reported that the facility staff and residents almost fell when they stepped on it. The need to ensure the facility provided a safe environment and to prevent tripping hazards was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator/universal worker) on 08/29/24. They acknowledged the findings.

1) Had carpet one in baker city come in to do measurments. We are waiting for a response and quote. If they are not able to, the offered to help find a contractor. The bathroom floor in room 9 was temporarily screwed down to fix bubble in floor to help hinder/ lower tripping hazard as suggested by other state surveyor. 2)Keep floors stain and debis free, and in good repair. We will keep a log of any new stains, bubbles or tears throughout the building. It will be checked weekly and added to weekly shampoo schedule. 3)will have weekly shampoo schedule 4) administrator/assistant admin

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

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to thoroughly investigate allegations of suspected abuse involving a resident-to-resident altercation and failed to report the incident to the local Seniors and People with Disabilities (SPD) office for 1 of 1 sampled resident (#1) who experienced a resident to resident altercation. Findings include, but are not limited to: Resident 1 moved into the facility in 07/2024 with diagnoses including dementia. Resident 1 ambulated independently around the facility without using an assistive device. The resident was an unsteady and had an imbalanced gait. Review of the resident’s clinical record, noted the resident was involved in a resident to resident physical altercation on 07/17/24. Staff documented the resident became upset, grabbed another resident’s arm, and squeezed, which resulted in two skin tears on the other resident. There was no documented evidence the incidents were reported to the local SPD. Also, there was no documented evidence the incidents had been thoroughly investigated, interventions determined, and necessary measures were taken to protect other residents and to prevent the reoccurrence of the suspected abuse. On 08/28/24, the surveyor requested Staff 1 (Administrator) and Staff 2 (Assistant Administrator/Universal worker) report the incident to the local SPD. On 08/29/24, the surveyor received verification the incident had been reported.

1) Will post administrative rule, and have inservice on when to call APD about person to person altercations. 2)Will post adinistrative rule for reminder. An inservice and demonatration of resident to resident combat/ abuse and when to call APD will be done every 3 months and anytime there is an incident. 3) anytime there is an incident 4) Administrator/assistant administrator

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by:

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs; This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide an activity program based on individual and group interest. Findings include, but are not limited to: An activity schedule for the facility was requested on 08/26/24. The current activity calendar noted the following: • 08/27/24 at 10:00 am and at 2:00 pm: Balloon toss and Puzzle; • 08/28/24 at 10:00 am: Posted Bean bag toss, but activity schedule indicated sitter size; and • 08/29/24 at 10:00 am: coloring. During survey observation on 08/27/24 and 08/28/24 from approximately 8:30 am to 3:30 pm, there were activities provided as scheduled. However, the activity did not last long, approximately 5 minutes or less. Throughout the survey, residents sat out in common areas for a long period of time, sleeping, while a television played continuously, walked the halls, or remained in their room, unengaged in individual and/or group activities. On 08/29/24, failure to provide an activity program based on individual needs and as a group was reviewed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator/Universal Worker). They acknowledged the findings.

1) We will go through charts and do individual activity plan by asking each resident their likes and dislikes. This way we will be able to come up with a more complex and enjoyable activity program. 2) We will perform quarterly evaluations on care plans for each resident and will change/update the activity program as needed if anything changes for each resident. 3) quarterly on care plans 4)administrator/assist

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs; This Rule is not met as evidenced by:

OAR 411-054-0034 (1-6) Resident Move-in and Eval: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must include the following information: (A) Prior living arrangements; (B) Emergency contacts; (C) Service plan involvement - resident, family, and social supports; (D) Financial and other legal relationships, if applicable, including, but not limited to:(i) Advance directives;(ii) Guardianship;(iii) Conservatorship; and(iv) Power of Attorney. (E) Primary language; (F) Community connections; and (G) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule.(a) Resident evaluations must be:(A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and(B) Performed at least quarterly, to correspond with the quarterly service plan updates.(C) Reviewed and any updates must be documented each time a resident has a significant change in condition.(D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident.(E) Documented, dated, and indicate who was involved in the evaluation process.(b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location.(c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations.(3) EVALUATION REQUIREMENTS AT MOVE-IN.(a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in.(b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in.(c) The initial evaluation must contain the elements specified in section (5) of this rule, and address sufficient information to develop an initial service plan to meet the resident's needs.(d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility.(e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation.(4) QUARTERLY EVALUATION REQUIREMENTS.(a) Resident evaluations must be performed quarterly after the resident moves into the facility.(b) The quarterly evaluation is the basis of the resident's quarterly service plan.(c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff.(d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained.(5) The resident evaluation must address the following elements:(a) Resident routines and preferences including:(A) Customary routines, such as those related to sleeping, eating, and bathing;(B) Interests, hobbies, and social and leisure activities;(C) Spiritual and cultural preferences and traditions; and(D) Additional elements as listed in 411-054-0027(2).(b) Physical health status including:(A) List of current diagnoses;(B) List of medications and PRN use;(C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and(D) Vital signs if indicated by diagnoses, health problems, or medications.(c) Mental health issues including:(A) Presence of depression, thought disorders, or behavioral or mood problems;(B) History of treatment; and(C) Effective non drug interventions.(d) Cognition, including:(A) Memory;(B) Orientation;(C) Confusion; and(D) Decision-making abilities.(e) Personality, including how the person copes with change or challenging situations.(f) Communication and sensory abilities including:(A) Hearing;(B) Vision;(C) Speech;(D) Use of assistive devices; and(E) Ability to understand and be understood.(g) Activities of daily living including:(A) Toileting, bowel, and bladder management;(B) Dressing, grooming, bathing, and personal hygiene;(C) Mobility ambulation, transfers, and assistive devices; and(D) Eating, dental status, and assistive devices.(h) Independent activities of daily living including:(A) Ability to manage medications;(B) Ability to use call system;(C) Housework and laundry; and(D) Transportation.(i) Pain pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort.(j) Skin condition.(k) Nutrition habits, fluid preferences, and weight if indicated.(l) List of treatments type, frequency, and level of assistance needed.(m) Indicators of nursing needs, including potential for delegated nursing tasks.(n) Review of risk indicators including:(A) Fall risk or history;(B) Emergency evacuation ability;(C) Complex medication regimen;(D) History of dehydration or unexplained weight loss or gain;(E) Recent losses;(F) Unsuccessful prior placements;(G) Elopement risk or history;(H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and(I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan.(o) Environmental factors that impact the resident's behavior including, but not limited to:(A) Noise.(B) Lighting.(C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 1) whose initial evaluation was reviewed. Findings include, but are not limited to: Resident 1 moved into the facility in 07/2024 with diagnoses including dementia. The initial evaluation was reviewed and failed to address the following required elements: • Customary routines including sleeping, eating and bathing; • Interests, hobbies, social, leisure activities; • Spiritual, cultural preferences and traditions; • Physical health status including list of current diagnoses, list of medications and PRN use, visits to health practitioner(s) ER, hospital or NF in the past year and vital signs if indicated by diagnosis, health problems or medications; • Mental Health issues including, presence of depression, though disorders or behavioral or mood problems, history of treatment and effective non-drug interventions; • Independent activity of daily living including ability to use call system; • Pain including pharmaceutical and non-pharmaceutical interventions and how a person expressed pain or discomfort; • Nutrition habits and fluid preference; • List of treatments; • Indicators of nursing needs including potential for delegated nursing tasks; • Fall risk or history; • Complex medication regimen; • History of dehydration or unexplained weight loss or gain; • Recent loss; and • Smoking, ability to smoke safety. The need to ensure the move-in evaluation included all required elements was discussed with Staff 1 (Administrator) and Staff 2 (Assistant administrator/Universal Worker) on 08/29/24. Staff acknowledged the findings.

1)The action that will be taken will be to update new pre admit forms to follow the OARs needed for admission for each new resident. 2)Keep updated new admit form when doing pre admittance. Make sure to check all areas as outlined in the OARS during evaluation. 3) upon admission and quarterly 4)administrator/assist

OAR 411-054-0034 (1-6) Resident Move-in and Eval: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must include the following information: (A) Prior living arrangements; (B) Emergency contacts; (C) Service plan involvement - resident, family, and social supports; (D) Financial and other legal relationships, if applicable, including, but not limited to:(i) Advance directives;(ii) Guardianship;(iii) Conservatorship; and(iv) Power of Attorney. (E) Primary language; (F) Community connections; and (G) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule.(a) Resident evaluations must be:(A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and(B) Performed at least quarterly, to correspond with the quarterly service plan updates.(C) Reviewed and any updates must be documented each time a resident has a significant change in condition.(D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident.(E) Documented, dated, and indicate who was involved in the evaluation process.(b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location.(c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations.(3) EVALUATION REQUIREMENTS AT MOVE-IN.(a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in.(b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in.(c) The initial evaluation must contain the elements specified in section (5) of this rule, and address sufficient information to develop an initial service plan to meet the resident's needs.(d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility.(e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation.(4) QUARTERLY EVALUATION REQUIREMENTS.(a) Resident evaluations must be performed quarterly after the resident moves into the facility.(b) The quarterly evaluation is the basis of the resident's quarterly service plan.(c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff.(d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained.(5) The resident evaluation must address the following elements:(a) Resident routines and preferences including:(A) Customary routines, such as those related to sleeping, eating, and bathing;(B) Interests, hobbies, and social and leisure activities;(C) Spiritual and cultural preferences and traditions; and(D) Additional elements as listed in 411-054-0027(2).(b) Physical health status including:(A) List of current diagnoses;(B) List of medications and PRN use;(C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and(D) Vital signs if indicated by diagnoses, health problems, or medications.(c) Mental health issues including:(A) Presence of depression, thought disorders, or behavioral or mood problems;(B) History of treatment; and(C) Effective non drug interventions.(d) Cognition, including:(A) Memory;(B) Orientation;(C) Confusion; and(D) Decision-making abilities.(e) Personality, including how the person copes with change or challenging situations.(f) Communication and sensory abilities including:(A) Hearing;(B) Vision;(C) Speech;(D) Use of assistive devices; and(E) Ability to understand and be understood.(g) Activities of daily living including:(A) Toileting, bowel, and bladder management;(B) Dressing, grooming, bathing, and personal hygiene;(C) Mobility ambulation, transfers, and assistive devices; and(D) Eating, dental status, and assistive devices.(h) Independent activities of daily living including:(A) Ability to manage medications;(B) Ability to use call system;(C) Housework and laundry; and(D) Transportation.(i) Pain pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort.(j) Skin condition.(k) Nutrition habits, fluid preferences, and weight if indicated.(l) List of treatments type, frequency, and level of assistance needed.(m) Indicators of nursing needs, including potential for delegated nursing tasks.(n) Review of risk indicators including:(A) Fall risk or history;(B) Emergency evacuation ability;(C) Complex medication regimen;(D) History of dehydration or unexplained weight loss or gain;(E) Recent losses;(F) Unsuccessful prior placements;(G) Elopement risk or history;(H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and(I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan.(o) Environmental factors that impact the resident's behavior including, but not limited to:(A) Noise.(B) Lighting.(C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. This Rule is not met as evidenced by:

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411-004-0030, the facility must incorporate all elements identified in the person-centered service plan into the resident's service plan.(2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence.(a) The service plan must be completed:(A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and(B) Following quarterly evaluations.(b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services.(c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided.(d) Changes and entries made to the service plan must be dated and initialed.(e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed.(f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative.(g) The facility administrator is responsible for ensuring the implementation of services.(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 move- in to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences.(c) Staff must document and date adjustments or changes as applicable.(4) QUARTERLY SERVICE PLAN REQUIREMENTS.(a) Service plans must be completed quarterly after the resident moves into the facility.(b) The quarterly evaluation is the basis of the resident's quarterly service plan.(c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding the delivery of service for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: 1.Resident 1 moved into the facility in 07/2024 with diagnoses including dementia. Observations of the resident, interviews with staff and current service plan reviewed during the survey, from 08/26/24 thru 08/29/24, revealed Resident 1's service plan was not reflective of the resident's status and did not provided clear directions regarding the delivery of services including what, when, how and how often the service should be provided in the following: • Activity preferences; • Nutrition habits and fluid preferences; • Oral health status; • Behaviors including putting self on the floor; • Showers; • Meal intake status including spitting out food; • Use of glasses; and • Personal hygiene. On 08/29/24, the service plan was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator/Universal Worker). They acknowledged the service plans were not reflective of the resident's status and lacked clear directions. 2.Resident 2 moved into the facility in 08/2019 with diagnoses including glaucoma. Observations of the resident, interviews with staff and current service plan reviewed during the survey, from 08/26/24 thru 08/29/24, revealed Resident 2's service plan was not reflective of the resident's status and did not provide clear directions regarding the delivery of services including what, when, how and how often the service should be provided in the following: • Activity preferences; • Receiving outside provider service including when to call or who to contact; • Use of glasses; • Use of Trapeze; • Personal hygiene; • Skin status; and • Catheter care and perineal care. On 08/29/24, the service plan was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator/Universal Worker). They acknowledged the service plans were not reflective of the resident's status and lacked clear directions.

1) add all administrative rules to care plan that need to be added. Will add everything on CBC resident review form (blue) to care plans. 2)adding the rules by being more in depth and giving clear directions regarding the delivery of services for each resident so that they are there when doing the care plan. 3)quarterly 4) administrator/assist

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.(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 move- in 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 monitor short term changes of condition through resolution for 2 of 5 sampled residents (#s 1 and 3) who experienced short term changes of condition. Findings include but are not limited to: 1.Resident 1 moved into the facility in 07/2024 with diagnoses including dementia. Resident 1's clinical records were reviewed during the survey and the following was noted: • 07/02/24: Move-in and new environment; and • 07/17/24: involved in a resident to resident physical altercation. There was no documented evidence that the resident's short-term changes of condition were monitored to resolution. 08/29/24, the above information was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator/Universal Worker). They acknowledged the findings. 2.Resident 2 moved into the facility in 08/2019 with diagnoses including glaucoma. Resident 2's clinical records were reviewed during the survey and the following was noted: • 04/24/24: Receiving anti-biotic treatment; • 05/15/24: Left toe skin status; • 06/06/24: Ingrowing toe nail status; and • 08/05/24: Buttocks skin status. There was no documented evidence that the resident's short-term changes of condition were monitored to resolution. 08/29/24, the above information was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator/Universal Worker). They acknowledged the findings.

1) print administrative rule knowing what a CHANGE OF CONDITION is SHORT or SIGNIFICANT and when it needs to be applied or charted. Apply to alert charting and careplan for each resident and updated as needed. 2) Will be added to alert charting and careplan as needed for each change of condition a resident has. 3) as resident is placed on alert charting/updateding careplan 4) administrator/assistant

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 411-054-0055 (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 MARs were accurate and included resident-specific parameters and staff instruction for 2 of 2 sampled residents (#s 1 and 2) whose medications were reviewed. Findings include, but are not limited to: 1.Resident 1 moved into the facility in 07/2024 with diagnoses including dementia. Resident 1’s 08/01/24 thru 08/26/24 MARs were reviewed during the survey and were found to be lacking accurate information and resident specific parameters to guide unlicensed staff in the following area: • Reason for the use of medication administrations for numerous medications; and • Multiple PRN bowel care medications lacked clear parameters for when to administer and which medication to be given first. On 08/29/24, the need for resident specific parameters and clear instruction to unlicensed staff was discussed with Staff 1 (Administrator) and Staff 2 (Assistance Administrator/Universal Worker). They acknowledged the findings. 2. Resident 2 moved into the facility in 08/2019 with diagnoses including glaucoma. Resident 2’s 08/01/24 thru 08/26/24 MARs were reviewed during the survey and were found to be lacking accurate information and resident specific parameters to guide unlicensed staff in the following area: • Reason for the use of medication administration for numerous medications. On 08/29/24, the need for resident specific parameters and clear instruction to unlicensed staff related to use of the medications was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator/Universal Worker). They acknowledged the findings.

1) when entering meds in the mar, we will also add an area for orders in the directions to be followed and be visible to see once the MAR is printed out for outsiders to see as staff can see physicions orders. 2)it will be added to the mar for each medication so that is is visible for outsiders to read when needed. 3) when a new med is entered 4) administrator/assistant

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 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with potential restraining qualities was assessed thoroughly by an RN, PT or OT prior to use, to provide instruction to the caregivers on the correct use and precautions and failed to evaluate the use of the device on a quarterly basis for 1 of 1 sampled resident (# 3) who had bilateral half-length side rails on their bed. Findings include, but are not limited to: Resident 3 was observed to have bilateral half-length side rails on the bed, in the up position which were identified to be devices with potentially restraining qualities. Review of the resident's clinical record showed the following: • No documented evidence of an assessment completed by a RN, Physical Therapist or Occupational therapist for the use of the side rails. Therefore, there was no documented evidence of other less restrictive alternatives had been attempted prior to their use; and • No instruction on the service plan to caregivers related to use and precaution of the side rails. On 08/29/24, the lack of documented assessment and care instructions for the use of the side rails was reviewed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator/Universal Worker). They acknowledged the findings.

1) All orders need to be seen by administrator. All supportive devices with restraning qualities need to be evaluated by OT,PT, and RN before being applied. 2)All orders that come in will be in box for administrator/RN, so that they can be seen and signed off on. Once orders are signed then device can be applied and orders will be charted in their charts. 3)when orders come in 4)administrator/assistant

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

OAR 411-054-0037 (4)(5)(6)(a-b)(C) Acuity Based Staffing Tool: Frequency of 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 ABST (Acuity Based Staffing Tool) was updated at least quarterly to determine appropriate staffing levels to address activities of daily living and other tasks related to care. Findings include, but are not limited to: The facility had a census of 13 residents at the time of survey. Review the facility’s ABST Tool showed 10 of 13 residents’ ABST information was not updated quarterly to reflect the residents’ current care needs and status, in order to ensure the ABST was accurately determining the needed staffing levels. On 08/28/24, the need to ensure the ABST tool was updated no less than quarterly to determine appropriate staffing levels to address activities of daily living and other tasks related to care was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator/Universal Worker). They acknowledged the findings.

1) Makin sure to access ABST when doing careplans. Updating ABST with new move ins, move outs or even deaths. Updating with any change of conditon for each resident. 2) When updating careplans, we will also make sure to update ABST by sending the link with any changes as needed. Will make sure to continue updating all staff as needed. 3)every 90 days/CHANGE OF CONDITION 4) administrator/assistant

OAR 411-054-0037 (4)(5)(6)(a-b)(C) Acuity Based Staffing Tool: Frequency of 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 411-054-0070 (3-4) Staffing Rqmts and Training: Caregiver Rqmts (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES.(a) Prior to beginning their job responsibilities, all employees must complete an orientation that includes training regarding:(A) Residents' rights and the values of community-based care.(B) Abuse and reporting requirements.(C) Standard precautions for infection control.(D) Fire safety and emergency procedures.(b) If the staff member's duties include preparing food, they must have a food handler's certificate.(c) All staff must receive a written description of their job responsibilities.(d) PRE-SERVICE INFECTIOUS DISEASE PREVENTION TRAINING. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-monthperiod prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula:(A) Transmission of communicable disease and infections, including:(i) Policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Respiratory hygiene and coughing etiquette.(B) Standard precautions.(C) Hand hygiene.(D) Use of personal protective equipment.(E) Cleaning of physical environment, including, but not limited to:(i) Disinfecting high-touch surfaces and equipment.(ii) Handling, storing, processing and transporting linens to prevent the spread of infection.(F) Isolating and cohorting of residents during a disease outbreak.(G) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (H) Facilities will be required t have all staff trained, as described in this rule, by July 1, 2022.(e) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff.(A) The pre-service training may be provided in person, in writing, by webinar or by other electronic means.(B) Online training will be made available by the Department by January 1, 2022.(C) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval.(D) The Department will review training from facilities or other entities with the goal of making training available to facilities by January 1, 2022.(f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete theDepartment-approved HCBS training, as provided below:(A) Effective March 31, 2024, all staff must have completed the required training.(B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning jobresponsibilities.(4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF.(a) Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training.(b) Pre-service dementia care training requirements for:(A) 2018 - Direct care staff hired on or before December 31, 2018 shall complete pre-service dementia care training outlined in OAR 411-054-0070 by December 31, 2018, regardless of when they first provide direct care to residents.(B) 2019 and beyond - Direct care staff hired on or after January 1, 2019 shall complete required pre-service dementia training prior to providing direct care to residents.(c) Documentation of dementia training:(A) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training.(B) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff.(d) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility ' s pre-service dementia training.(e) A certificate of completion must be made available to the Department upon request.(f) Pre-service dementia care training must include the following subject areas:(A) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms.(B) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses.(C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities.(D) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to:(i) Identify and address pain.(ii) Provide food and fluids.(iii) Prevent wandering and elopement.(iv) Use a person-centered approach.(g) Pre-service orientation to resident:(A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident's service plan.(B) Staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure all pre-service orientation topics had been completed prior to staff beginning their job duties for 1 of 3 sampled newly-hired staff (# 6), infectious disease preventions training for 2 of 2 sampled newly-hired staff (#s 4 and 5) and HCBS training within required time frame for 2 of 2 sampled long term staff (#s 7 and 8). Findings include, but are not limited to: The facility's training records were reviewed on 08/28/24 and the following was identified: a.There was no documented evidence Staff 6 (Universal Worker), hired 04/01/24, completed the following pre-service orientation topics prior to beginning their job duties: • Resident rights and the values of community-based care; • Abuse and reporting requirements; • Infectious disease prevention training; • Fire safety and emergency procedures; and • HCBS course. b. There was no documented evidence Staff 4 (Universal Worker) and Staff 5 (Caregiver) hired 03/13/24 and 04/01/24, completed infectious disease prevention training. c. There was no documented evidence Staff 7 (Universal Worker) and Staff 8 (Universal Worker), hired 02/16/17 and 08/12/22, completed the required HCBS training by 03/31/24. The requirements for pre-service orientation, infectious disease preventions and HCBS training for all employees was reviewed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator/Universal Worker) on 08/28/24. Staff acknowledged the findings.

1) Assistant will have an updated paper packet chart that goes with the new hire paper work showing, what to do before hire, 30 days after hire date, 90 days after hire date, and annually. 2) We will perfom instant inservice to show the chart to current staff and then explain to new staff when they are hired what has to be done before and after hire and as needed. 3) every 90 days at meeting 4)assistant/administrator

OAR 411-054-0070 (3-4) Staffing Rqmts and Training: Caregiver Rqmts (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES.(a) Prior to beginning their job responsibilities, all employees must complete an orientation that includes training regarding:(A) Residents' rights and the values of community-based care.(B) Abuse and reporting requirements.(C) Standard precautions for infection control.(D) Fire safety and emergency procedures.(b) If the staff member's duties include preparing food, they must have a food handler's certificate.(c) All staff must receive a written description of their job responsibilities.(d) PRE-SERVICE INFECTIOUS DISEASE PREVENTION TRAINING. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-monthperiod prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula:(A) Transmission of communicable disease and infections, including:(i) Policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Respiratory hygiene and coughing etiquette.(B) Standard precautions.(C) Hand hygiene.(D) Use of personal protective equipment.(E) Cleaning of physical environment, including, but not limited to:(i) Disinfecting high-touch surfaces and equipment.(ii) Handling, storing, processing and transporting linens to prevent the spread of infection.(F) Isolating and cohorting of residents during a disease outbreak.(G) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (H) Facilities will be required t have all staff trained, as described in this rule, by July 1, 2022.(e) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff.(A) The pre-service training may be provided in person, in writing, by webinar or by other electronic means.(B) Online training will be made available by the Department by January 1, 2022.(C) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval.(D) The Department will review training from facilities or other entities with the goal of making training available to facilities by January 1, 2022.(f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete theDepartment-approved HCBS training, as provided below:(A) Effective March 31, 2024, all staff must have completed the required training.(B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning jobresponsibilities.(4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF.(a) Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training.(b) Pre-service dementia care training requirements for:(A) 2018 - Direct care staff hired on or before December 31, 2018 shall complete pre-service dementia care training outlined in OAR 411-054-0070 by December 31, 2018, regardless of when they first provide direct care to residents.(B) 2019 and beyond - Direct care staff hired on or after January 1, 2019 shall complete required pre-service dementia training prior to providing direct care to residents.(c) Documentation of dementia training:(A) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training.(B) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff.(d) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility ' s pre-service dementia training.(e) A certificate of completion must be made available to the Department upon request.(f) Pre-service dementia care training must include the following subject areas:(A) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms.(B) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses.(C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities.(D) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to:(i) Identify and address pain.(ii) Provide food and fluids.(iii) Prevent wandering and elopement.(iv) Use a person-centered approach.(g) Pre-service orientation to resident:(A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident's service plan.(B) Staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable. This Rule is not met as evidenced by:

OAR 411-054-0070 (6)(9) Training within 30 days: Direct Care Staff "Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (6) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF.(a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned.(b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to:(A) The role of service plans in providing individualized resident care.(B) Providing assistance with the activities of daily living.(C) Changes associated with normal aging.(D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition.(E) Conditions that require assessment, treatment, observation and reporting.(F) General food safety, serving and sanitation.(G) If the direct care staff person ' s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised.(9) ADDITIONAL REQUIREMENTS. Staff:(a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services.(b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required.(c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed." This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure and document that direct care staff demonstrated knowledge and performance in all required areas within 30 days of hire for 1 of 3 newly-hired staff (# 6). Findings include, but are not limited to: The facility's training records were reviewed on 08/28/24 and the following was identified: There was no documented evidence Staff 6 (Universal Worker), hired 04/01/24, demonstrated knowledge and satisfactory performance in the following topics: • Role of service plans in providing individualized care; • Providing assistance with ADLs; • Changes associated with normal aging; • Identification, documentation and reporting of changes of condition; • Conditions that require assessment, treatment, observation and reporting; and • Medication pass. The need to ensure the facility documented direct care staff demonstrated knowledge and performance in all required areas within 30 days of hire was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator/ Universal Worker) on 08/28/24. Staff acknowledged the findings.

1) Assistant will have an updated paper packet chart that goes with the new hire paper work showing, what to do before hire, 30 days after hire date, 90 days after hire date, and annually. 2) We will perfom instant inservice to show the chart to current staff and then explain to new staff when they are hired what has to be done before and after hire and as needed. 3) every 90 days at meeting 4)assistant/administrator

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

OAR 411-054-0070 (2-5)(5-8) Annual Training and Other Requirements (2) An administrator of a facility and the employees of the facility, as specified by the Department of Human Services by rule, must receive training in recognizing disease outbreaks and infection control at the time of hiring, unless the administrator or the employee has received the training at another facility within the 24-month period prior to the time of hiring, and annually as part of, and not in addition to, the administrator or employee's continuing education requirements.(3) The department, in consultation with the Oregon Health Authority, shall prescribe by rule the requirements for the training, which must include at least the following: (a) How to properly prevent and contain disease outbreaks based on the current best evidence in the field of infection and disease outbreak identification, prevention and control;And (b) The responsibility of staff members to report disease outbreaks under ORS 433.004.(4) The training may be provided in person, in writing, by webinar or by other electronic means. The department shall make online trainings available.(5)(a) A facility must establish and maintain infection prevention and control protocols designed to provide a safe, sanitary and comfortable environment and to prevent the development and transmission of communicable diseases.(5) ANNUAL INSERVICE FOR ALL STAFF. Annual infectious disease training requires the following:(a) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training.(b) Annual in-service training must be documented in the employee record.(c) These annual training requirements will be required as of July 1, 2023.(7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF.(a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population and dementia training. Annual in-service training hours are based on the anniversary date of hire.(b) Requirements for annual in-service dementia training:(A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care.(B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter.(C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above.(D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia.(E) The facility shall determine the competency of direct care staff in dementia care in the following ways:(i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19).(ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff.(iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee ' s assessed competency.(8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have documented evidence that 12 hours of annual in-service training, including six hours related to the care of the dementia resident, was completed for 2 of 3 long-term staff (#s 7 and 8) and completed annual infectious disease training for 2 of 2 long-term staff (#s 7 and 9) whose training records were reviewed. Findings include, but are not limited to: Facility staff training records were reviewed on 08/28/24 and revealed the following: a.Training records for Staff 7 (Universal Worker), hired 02/16/17 and Staff 8 (Universal Worker), hired 08/12/22, based on their anniversary date of hire, did not have documented evidence of required annual in-service training, including six hours relating to the care of residents with dementia based on anniversary date of hire. The need to ensure staff completed the required annual in-service training, based on anniversary dates of hire and infectious disease training was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator/Universal Worker) on 08/28/24. Staff acknowledged the findings. b. Training records for Staff 7 and Staff 9 (Universal Worker), re-hired 08/12/15, did not have documented evidence of annual required infectious disease training. The need to ensure staff completed the required annual in-service training, based on anniversary dates of hire and infectious disease training was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator/Universal Worker) on 08/28/24. Staff acknowledged the findings.

1) Assistant will have an updated paper packet chart that goes with the new hire paper work showing, what to do before hire, 30 days after hire date, 90 days after hire date, and annually. 2) We will perfom instant inservice to show the chart to current staff and then explain to new staff when they are hired what has to be done before and after hire and as needed. 3) every 90 days at meeting 4)assistant/administrator

OAR 411-054-0070 (2-5)(5-8) Annual Training and Other Requirements (2) An administrator of a facility and the employees of the facility, as specified by the Department of Human Services by rule, must receive training in recognizing disease outbreaks and infection control at the time of hiring, unless the administrator or the employee has received the training at another facility within the 24-month period prior to the time of hiring, and annually as part of, and not in addition to, the administrator or employee's continuing education requirements.(3) The department, in consultation with the Oregon Health Authority, shall prescribe by rule the requirements for the training, which must include at least the following: (a) How to properly prevent and contain disease outbreaks based on the current best evidence in the field of infection and disease outbreak identification, prevention and control;And (b) The responsibility of staff members to report disease outbreaks under ORS 433.004.(4) The training may be provided in person, in writing, by webinar or by other electronic means. The department shall make online trainings available.(5)(a) A facility must establish and maintain infection prevention and control protocols designed to provide a safe, sanitary and comfortable environment and to prevent the development and transmission of communicable diseases.(5) ANNUAL INSERVICE FOR ALL STAFF. Annual infectious disease training requires the following:(a) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training.(b) Annual in-service training must be documented in the employee record.(c) These annual training requirements will be required as of July 1, 2023.(7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF.(a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population and dementia training. Annual in-service training hours are based on the anniversary date of hire.(b) Requirements for annual in-service dementia training:(A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care.(B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter.(C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above.(D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia.(E) The facility shall determine the competency of direct care staff in dementia care in the following ways:(i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19).(ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff.(iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee ' s assessed competency.(8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process. This Rule is not met as evidenced by:

OAR 411-054-0090 (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 document all required components of fire drills and failed to ensure fire and life safety instruction was provided on alternate months to staff. Findings include, but are not limited to: 1.Review of fire drill record on 01/08/24, dated 08/24/24, showed the facility failed to document the following required components: • Problems encountered, comments relating to residents who resisted or failed to participate in the drills; and • Staff members on duty and Participating. 2. The facility failed to provide documented evidence that fire and life safety instruction was being provided to staff on alternating months from fire drills. On 08/28/24, the need to ensure all required components of fire drills were documented, fire and life safety instruction was provided on alternate months to staff was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator/Universal Worker). Staff acknowledged the findings.

1) We will update our fire drill papers to include A) any problems that were encountered during a fire drill B) Add available space to put any comments relating to residents who resisted to perfom in fire drill. C) Make sure staff members are writing down who is on duty and who participated D) Make sure we are performing the correct fire and life safety inservices that follow the OARs. 2) We will have an updated fire drill sheet. We will conduct fire and safety instructions and inservices every other month. We will contact the fire department and ask if they can come in and demonstrate/preform these inservices. 3.) Every 30 days 4) assistant/administrator

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 each resident was 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. Findings include, but are not limited to: In an interview on 08/28/24 with Staff 2 (Assistant Administrator/Universal Worker), she stated the facility was not providing or documenting annual instruction for residents 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. Additionally, she was not aware of fire life safety instruction with residents within 24 hours of admission. The requirements for fire life safety instruction for residents were reviewed with Staff 1 (Administrator) and Staff 2 on 08/28/24. They acknowledged the findings.

1) add in more detail on careplan about the role the resident has in the event of a fire. Make sure it is noted when the resident is admitted that we went over what happens in the event of a fire. Docment if they do or do not understand. Make sure this information is gone over with each resident annually. 2) add to resident's care plan in more detail about the event of a fire. Document the resident's understanding. Make sure we go over and document the resident's responsibility during the fire drills and the designated meeting place. 3) every 90 days 4) administrator/assistant

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

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C513.

1.) Actions that will be taken include requesting an extension on being able to have our flooring redone. We will also continue to look for more options on who to go through for our floors so we can get a date and plan set in action. 2.) This system will be corrected by continuing our search of finding affordable flooring and making/picking a date to have the floors done. Once this step is completed, pictures will be provided to the state to show that we will be/are in compliance to C455 and C513. 3.) This area will be evaluated weekly until we are able to get the flooring replaced. Once the flooring is replaced, the floors will continue to be checked weekly to make sure there is no new damage. 4.) Those responsible to see that the corrections are completed/monitored will be Nicole Howerton and Tiffani Heitz.

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

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to maintain all interior surfaces in good repair. Findings include, but are not limited to: The interior of the building was toured on 08/26/24. The following areas needed repair: • The carpet throughout the facility was worn out, threadbare, and uneven and had spots and stains; Additionally, multiple areas on the carpet were screwed down in the bubbled-up regions; • Room 9’s bathroom floor was bulging and bumpy; • Room 7, 12, 13 and 14’s door were chipped, dinged, gouged, scratched and scuffed; • Door frame in Room 2, 3 and sunroom and staff laundry room were chipped, dinged, gouged, scratched and scuffed; • Multiple chairs in common and sunroom areas were worn out and had white matter; • Sunroom floor had missing laminate and a broken blind; • Missing laminate floor in staff laundry room; • Dining room walls were chipped and gouged; • Ceiling vents throughout the facility had a layer of dust; • Spider web near Room 3; • Water damage and a hole on the ceiling near clean linen closet; • In the hallway there was a missing light fixture, near Room 5; and • There was a pervasive odor and a layer of dust on sink, washers and dryers in staff laundry room. On 08/28/24, the areas in need of repair were reviewed with Staff 1 (Administrator). Staff acknowledged the findings.

1)Will update Noc cleaning log with places for door ways, door frames, walls, vents, light fixtures, (give spiderman a 30 day notice). We have contacted Carpet one to have them come inspect facility to give us a quote on new carpet installment. 2) The carpet and laminate floors will be getting quoted so that they can be repaired. Room 9's bathroom floor was screwed down temporarily to lesson the trip hazard as suggested by second state surveyor. All doors, door frames and walls will be checked every two weeks for any chips, dings, gouges, scratches and scuffs. If any are found they will be fixed. Chairs in common sunroom will be added to the weekly shampoo list. Cleaning vents throughout the facility will be more implicated and added to cleaning list for mulptiple shifts for weekly cleaning. Dusting will be added to multiple shift duties. Water damage and hole in ceiling will be fixed and taken care of. Light fixture in hallway near room five will be replaced. Laundry room dusting will be aded to multiple shifts for cleaning throughout the week. And staff will take the garbage out more often so that the odor is not noticed. 3) weekly 4) administrator/assistant

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. This is a repeat citation. Findings include, but are not limited to: Observations of the facility on 03/10/25 and 03/11/25 showed the following areas in need of cleaning or repair: * Multiple carpet stains, of varying sizes, were noted to the carpet in the living room and hallways throughout the facility. Edges and seams of the carpet was frayed and/or pulling apart in several locations. Numerous pieces of duct tape were in place on seams, as well as areas that were coming apart more significantly, to help eliminate any potential trip hazards; * Laminate flooring in the sunroom and dining room was pulling apart at the seams, had large gaps, missing pieces and/or gouges; * The laundry room flooring had multiple chips, large chunks of missing flooring, cracks in the floor and spills/stains to the floor near the machines; * Room 9 had chips, dings and uneven flooring noted in the bathroom. There was no resident living in room 9 at this time; * Room 5 had significant fraying and loose edges at the edge near the doorway; and * Room 14 had a small section of frayed and separating carpet near the center of the room. The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator) on 03/10/25 and 03/11/25. The staff acknowledged the findings.

1.) Actions that will be taken include requesting an extension on being able to have our flooring redone. We will also continue to look for more options on who to go through for our floors so we can get a date and plan set in action. 2.) This system will be corrected by continuing our search of finding affordable flooring and making/picking a date to have the floors done. Once this step is completed, pictures will be provided to the state to show that we will be/are in compliance to C455 and C513. 3.) This area will be evaluated weekly until we are able to get the flooring replaced. Once the flooring is replaced, the floors will continue to be checked weekly to make sure there is no new damage. 4.) Those responsible to see that the corrections are completed/monitored will be Nicole Howerton and Tiffani Heitz.

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

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure units had entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. Findings include, but are not limited to: During a tour of the facility, butter knives were observed placed in various locations of the hallways. In an interview on 08/29/24 at 12:00 pm, Staff 1 (Administrator) explained the facility had not been giving residents keys to their doors and used the butter knives to unlock resident room doors when necessary. Staff 1 did confirm each resident unit was keyed individually and there was a key available for each unit. The need to provide a key to each resident for their unit entrance door was reviewed with Staff 1 on 08/29/24. She acknowledged the findings and said she would issue residents a key to their units.

1.) Administrator bought new door handles and they will be delivered the 23rd. Door handles will be on all doors and each resident will have their own keys to their doors. A master key for each room will be given to the designated P.I.C on each shift. 2) This will be corrected by keeping the locking door handles on all residents' doors by putting new ones on. Residents will have their own keys to their rooms. A P.I.C that is designated for each shift will have the master keys to each room so that no other resident or staff member can get into the room without the P.I.C openin the door for them. 3) as they need ? 4) administrator/assistant

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