Print Inspection: RL000221

OAR 411-054-0025 (7) Facility Administration: Policy & Procedure (Amended 6/9/21)(7) POLICIES AND PROCEDURES. The facility must develop and implement written policies and procedures that promote high quality services, health and safety for residents, and incorporate the community-based care principles of individuality, independence, dignity, privacy, choice, and a homelike environment. The facility must develop and implement: (a) A policy on the possession of firearms and ammunition within the facility. The policy must be disclosed in writing and by one other means of communication commonly used by the resident or potential resident in his or her daily living. (b) A written policy that prohibits sexual relations between any facility employee and a resident who did not have a pre-existing relationship. (c) Effective methods of responding to and resolving resident complaints. (d) All additional requirements for written policies and procedures as established in OAR 411-054-0012 (Requirements for New Construction or Initial Licensure), OAR 411-054-0040 (Change of Condition and Monitoring), OAR 411-054-0045 (Resident Health Services), and OAR 411-054-0085 (Refunds and Financial Management). (e) A policy on smoking. (A) The smoking policy must be in accordance with: (i) The Oregon Indoor Clean Air Act, ORS 433.835 to 433.875; (ii) The rules in OAR chapter 333, division 015; and (iii) Any other applicable state and local laws. (B) The facility may designate itself as non-smoking. (f) A policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner. The policy must include information regarding the collection of medical and forensic evidence that must be obtained within 86 hours of the incident. (g) A policy on facility employees not receiving gifts or money from residents. (h) Protocols for preventing and controlling infection, as described in OAR 411-054-0050. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility lacked an effective method for responding to and resolving resident complaints. Findings include, but are not limited to: a. During a group interview with eight unsampled residents, multiple residents reported meals “needed improvement.” Specifically, residents reported vegetables were either overcooked and “mushy” or they were undercooked. They also reported that sometimes the meat was overcooked and dry. b. On 09/11/24 at 12:35 pm, an unsampled resident approached this surveyor to express his/her complaint that vegetables at most meals were overcooked and unpalatable. This was of concern to the resident because s/he followed a vegetarian diet. In an interview on 09/12/24 at 1:10 pm, Staff 15 (Cook) explained that for dinner service he prepared the vegetables by 3:30 pm so that room trays could be assembled and delivered to residents. The remaining vegetables were held in a pan on the steam table until meal service in the dining room began at 4:30 pm. Staff 15 said he sometimes added freshly cooked vegetables to the previously cooked vegetables already in the pan. Staff 15 stated he was aware of resident concerns regarding the vegetables being overcooked but said he did not have a plan to change the manner in which he prepared the meals. The residents’ complaint about the vegetables was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations), Staff 3 (Regional Director of Operations) and Staff 17 (Regional RN) on 09/12/24. Staff 1 stated he was aware of the complaints and acknowledged the facility had not yet formulated and implemented a solution to address the complaints.

1. The dining team implemented a new system when cooking vegetables and now cooks them in batches to prevent them from sitting too long and being overcooked. The dining team is testing the vegetables at meal times to ensure proper palatability. The servers have been trained to check in with the resident during meal times to ensure they are satisfied. 2. The community conducts monthly food committee meetings and resident townhall meetings. During these meetings, residents will provide feedback and the Management team will receive notes taken during meetings. Then, management team and appropriate departments will respond to residents in writing and post the minutes to the bulletin board in the common area to communicate resolution. The community will follow their greivance policy and have greivance forms available in a common area and will respond to all greivances verbally or in writing upon request and a greivance log will be maintained. 3. Monthly and as needed. 4. Executive Director

OAR 411-054-0025 (7) Facility Administration: Policy & Procedure (7) POLICIES AND PROCEDURES. The facility must develop and implement written policies and procedures that promote high quality services, health and safety for residents, and incorporate the community based care principles of individuality, independence, dignity, privacy, choice, and a homelike environment. The facility must develop and implement: (a) A policy on the possession of firearms and ammunition within the facility. The policy must be disclosed in writing and by one other means of communication commonly used by the resident or potential resident in his or her daily living. (b) A written policy that prohibits sexual relations between any facility employee and a resident who did not have a pre-existing relationship. (c) Effective methods of responding to and resolving resident complaints. (d) All additional requirements for written policies and procedures as established in OAR 411-054-0012 (Requirements for New Construction or Initial Licensure), OAR 411-054-0040 (Change of Condition and Monitoring), OAR 411-054-0045 (Resident Health Services), and OAR 411-054-0085 (Refunds and Financial Management). (e) A policy on smoking. (A) The smoking policy must be in accordance with: (i) The Oregon Indoor Clean Air Act, ORS 433.835 to 433.875; (ii) The rules in OAR chapter 333, division 015; and (iii) Any other applicable state and local laws. (B) The facility may designate itself as non-smoking. (f) A policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner. The policy must include information regarding the collection of medical and forensic evidence that must be obtained within 86 hours of the incident. (g) A policy on facility employees not receiving gifts or money from residents. (h) Protocols for preventing and controlling infection, as described in OAR 411-054-0050. (i) LGBTQIA2S+ Nondiscrimination Notice: “(Name of care facility) does not discriminate and does not permit discrimination, including but not limited to bullying, abuse or harassment, based on an individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status, or based on an individual’s association with another individual on account of the other individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status. If you believe you have experienced this kind of discrimination, you may file a complaint with the Oregon Department of Human Services at (provide current contact information).” (j) ABST Policy for accurate and consistent implementation of the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. This Rule is not met as evidenced by:

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to promptly investigate incidents to rule out abuse and report incidents to the local Seniors and People with Disabilities (SPD) office, if abuse or neglect could not be ruled out, for 1 of 1 sampled resident (#6) with injuries of unknown cause. Findings include, but are not limited to: Resident 6 was admitted into the facility in 06/2017 with diagnoses including chronic obstructive pulmonary disease, chronic pain, anxiety, and major depressive disorder. Resident 6’s outside provider documentation, dated 06/07/24 through 09/03/24, and progress notes, dated 06/10/24 through 09/09/24, were reviewed and the following was identified: * “Random bruising on hands;” * “…purple spot [one to two] inches down from wound;” * Resident self-reported a fall with no staff response; and * “Redness on [right] cheek near temporal mandibular joint.” On 09/10/24 at 1:50 pm, Staff 2 (Vice President of Operations) stated the facility did not have documented evidence the events had been investigated or reported to local SPD. The facility was asked to report the events to the local SPD office prior to survey exit. Confirmation was received on 09/11/24 at 9:35 am. The need to investigate injuries of unknown cause immediately and report the incidents to the local SPD office if abuse or neglect could not be ruled out was discussed with Staff 1 (ED), Staff 2, Staff 3 (Regional Director of Operations) and Staff 17 (Regional RN) on 09/12/24. They acknowledged the findings.

1. All incidents discovered during survey for resident #6 were investigated and reported to APS. 2. Executive Director, Licensed Nurses and Resident Care Coordinators reviewed the abuse and neglect reporting guidelines and the need for thorough and timely investigations. All staff received training on abuse investigation and reporting procedures. 3. Incident reports will be reviewed daily to ensure proper response and investigation. Any incidents requiring report to APS will be reported timely. 4. Executive Director, Director of Health Services

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 411-054-0034 (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 observation, interview and record review, it was determined the facility failed to ensure quarterly evaluations were completed in a timely manner for 2 of 3 sampled residents (#s 3 and 6) whose records were reviewed for the use of assisted devices. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 07/2022 with diagnoses including chronic heart failure. Observation of the resident's bed on 09/10/24 at 9:13 am revealed a bed rail on the bed. The rail was in the up position and the resident reported using it for bed mobility and transferring in and out of the bed. The resident said s/he had been using the rail for a while. Review of the resident’s records showed there was no evaluation for the use of the rail. In an interview with Staff 2 (Vice President of Operations) on 09/10/24, she confirmed that the device was not new to the resident. She further reported that during the evaluation on 09/09/24, the facility RN identified an issue with the current rail and directed the resident not to lower the bed until a new device could be installed. On 09/10/24 and 09/12/24, the lack of evaluation for the use of the device was discussed with Staff 1 (ED), Staff 2 and Staff 3 (Regional Director of Operations). They acknowledged the findings. 2. Resident 6 was admitted into the facility in 06/2017 with diagnoses including chronic obstructive pulmonary disease, chronic pain, anxiety, and major depressive disorder. The resident’s bed was observed to have bilateral side rails in the upright position throughout the survey. However, Resident 6 stated s/he did not use the bed because the air pressure mattress was uncomfortable. Resident 6’s most recent quarterly evaluation and side rail evaluation, dated 03/08/24 and 03/13/24 respectively, were reviewed and the following was identified: * The resident’s quarterly evaluation was not reviewed at least quarterly; and * The resident’s side rail evaluation was not completed quarterly. The need to ensure quarterly evaluations and side rail evaluations were performed at least quarterly was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations), Staff 3 (Regional Director of Operations) and Staff 17 (Regional RN) on 09/12/24. They acknowledged the findings.

1. Updated level of care evaluation, service plan and supportive device assessment to accurately reflect needs for Resident #3 and #6. Audited all current residents to verify their required evaluations and assessments were completed timely and accurately to reflect their needs. 2. Evaluation and assessment schedules will be reviewed during daily stand up meeting and all staff will receive training on reporting changes in resident care needs and environment to health services timely so resident evaluations are updated appropriately. Training conducted with health services team about the requirements of timely evaluations and assessments. 3. Weekly during clinical meeting and weekly Regional Team review. 4. Executive Director, Resident Care Coordinator, Director of Health Services

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: 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, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) 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) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) 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). (c) 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. (d) 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. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) 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. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) 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. (p) 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. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 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' current care needs and provided clear directions to staff regarding the delivery of services for 4 of 6 sampled residents (#s 2, 3, 5 and 6) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 07/2022 with diagnoses including type 2 diabetes mellitus, diastolic (congestive) heart failure and chronic obstructive pulmonary disease. Observations were made of the resident's care from 09/09/24 through 09/11/24. Interviews with the resident, facility staff and the resident’s outside provider were conducted. The current service plan dated 08/20/24 was reviewed. Resident 5's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Number of staff needed to assist with emergency evacuations; * Instructions for reporting signs and symptoms of depression while on anti-depressant therapy; * Instructions for bleeding precautions and interventions while on anticoagulation therapy; * Instructions to staff on blood glucose monitoring protocol when resident skipped meals; * Instructions on signs and symptoms of hypo- and hyperglycemia to report; * Instructions for proper maintenance of the resident’s blood sugar monitor on his/her right upper extremity and how to monitor for malfunctions; * Instructions on edema management; * Electric wheelchair equipment precautions and instructions for proper maintenance; * Use and safety monitoring of continuous positive airway pressure ventilation device; and * Dental status and assistive devices. The need to ensure the service plan reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (ED), Staff 2 (Vice President of Operations), and Staff 3 (Regional Director of Operations) on 09/12/24. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 11/2007 with diagnoses including head injury and muscle weakness. a. The resident’s service plan, which was available to staff, was completed on 11/21/23. It was not updated quarterly as required. b. Observation of the resident, interviews with the resident and staff, and current service plan reviewed during the survey, revealed Resident 2’s service plan did not provide clear instruction for the following: * Use of the bed rail including precautions for the rail use. On 09/12/24, the service plan was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations) and Staff 3 (Regional Director of Operations). They acknowledged the service plans were not updated quarterly and lacked clear directions. 3. Resident 3 was admitted to the facility in 07/2022 with diagnoses including chronic heart failure. Observation of the resident, interview with staff and the resident, and current service plan, dated on 08/30/24, reviewed during the survey, revealed Resident 3’s service plan was not reflective, provided conflicting directions or did not provide clear instructions the following: * Bowel and bladder status; * Required assistance with personal hygiene and oral care status; * Transfer status; * Toileting assistance; and * Use of a rail on the bed including precautions for the rail use. On 09/12/24, the service plan was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations) and Staff 3 (Regional Director of Operations). They acknowledged the service plans were not reflective, provided conflict direction and lacked clear directions. 4. Resident 6 was admitted to the facility in 06/2017 with diagnoses including chronic obstructive pulmonary disease, chronic pain, anxiety, and major depressive disorder. The resident's current service plan, dated 03/08/24, interim service plans dated 05/19/24 through 08/26/24, and 06/10/24 through 09/09/24 progress notes and outside provider summary sheets were reviewed, observations were made, and interviews were conducted, and the following was identified: a. The resident’s service plan had not been reviewed at least quarterly. b. The service plan was not reflective of the resident's needs and preferences and/or did not provide clear instruction to staff in the following areas: * Use of assistive devices and clear instruction regarding the use of a hospital bed, air pressure mattress, power recliner, and recliner cushion; * Use of a continuous positive airway pressure machine; * Oxygen equipment precautions, instructions for proper maintenance, and how to monitor for safety; * Tobacco and nicotine use; * Evening routine including bedtime and use of recliner; * Mental health including recent loses and non-pharmacological interventions; * Activity preferences including assistance needed for mobility and oxygen use; * Toileting schedule and assistance needed; * Laundry and assistance needed; * Nutritional habits and preferences including nutritional shakes and clear instruction; and * Preference to have the door to his/her room propped open. The need to ensure service plans were updated at least quarterly, were reflective of resident needs and preferences, and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations), Staff 3 (Regional Director of Operations) and Staff 17 (Regional RN). They acknowledged the findings.

1. Service plans for resident #2,3,5,and 6 were reviewed and updated to reflect resident's current care needs and have clear directions to staff regarding the delivery of services. 2. To prevent recurrance, all current resident service plans will be audited for accuracy. Direct care staff were reeducated regarding the importance of implementing current service plans and reporting any discrepancies. Training with Health Services team completed to ensure service plans are updated for accuracy and they provide clear direction to care team. 3. Service plans will be evaluated and reviewed upon admission, at 30 days, quarterly and with significant change of condition. 4. Executive Director and Health Services team.

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

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to determine what resident-specific actions or interventions were needed for a resident following a short-term change of condition, communicate the determined actions or interventions to staff, and document progress at least weekly until the condition resolved or monitored the resident consistent with their evaluated needs, for 5 of 6 sampled residents (#s 1, 3, 4, 5 and 6) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 07/2022 with diagnoses including type 2 diabetes mellitus, diastolic (congestive) heart failure and chronic obstructive pulmonary disease. Clinical records, including the current service plan, dated 08/20/24, and progress notes from 06/13/24 through 08/30/24 were reviewed, and interviews with facility staff were conducted. The following short-term changes of condition lacked documentation the facility determined what resident-specific actions or interventions were needed for the resident, communicated the determined actions or interventions to staff, and/or documented weekly progress until the condition resolved: 06/14/24: return to the facility after hospital admission related to hypoxemic respiratory failure; 06/14/24: “injury is a burn caused by a heating pad used in the hospital”; 06/14/24: “chronic wound to the left gluteal fold”; 06/16/24: nebulizer for physician prescribed treatments was not available; 06/16/24: non-witnessed fall; 06/19/24: order to stop torsemide (diuretic), start Bumex (diuretic), and decrease amlodipine (for blood pressure); 06/22/24: pregabalin (anticonvulsant) was not available; 07/10/24: skin impairment on right buttock, groin and pannus area are “sl [slightly] red”; 07/23/24: recorded oxygen saturation of 85% (out of normal range parameter) and “there was a bloody tissue on the floor…”; 08/02/24: “pressure ulcer pain-buttocks in sitting”; and 08/05/24: cataract surgery. The need to ensure the facility evaluated the resident and determined what resident-specific actions or interventions were needed for the resident following a short-term change of condition, communicated the determined actions or interventions to staff, and documented progress until the condition resolved was reviewed with Staff 1 (ED), Staff 2 (Vice President of Operations), and Staff 3 (Regional Director of Operations) on 09/12/24. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 07/2022 with diagnoses including chronic heart failure. Resident 3's weight record was reviewed during the survey and the following was noted: * 04/02/24 – 181 pounds; * 05/27/24 – 167 pounds; * 06/02/24 – 166.6 pounds; * 07/02/24 – 165.9 pounds; and * 08/31/24 – 182.6 pounds The record showed the resident had experienced weight loss between 04/02/24 and 07/02/24. There was no documented evidence actions or interventions were determined, documented and communicated to staff and the facility failed to document on the progress of the change of condition at least weekly until resolved. In an interview with Staff 2 (Vice President of Operations) and Staff 9 (Regional RN) confirmed there was no additional documentation for the change of condition. On 09/10/24 and 09/12/24, Resident 3’s change of condition in weight loss was discussed with Staff 1 (ED), Staff 2 and Staff 3 (Regional Director of Operations). They acknowledged the findings. 3. Resident 6 was admitted to the facility in 06/2017 with diagnoses including chronic obstructive pulmonary disease, chronic pain, anxiety, and major depressive disorder. The resident's current service plan, dated 03/08/24, interim service plans dated 05/19/24 through 08/26/24, and 06/10/24 through 09/09/24 progress notes and outside provider summary sheets were reviewed, observations were made, and interviews were conducted, and the following was identified: There was no documented evidence resident-specific actions or interventions were determined for short-term changes of condition, the actions or interventions were communicated on all shifts, and/or changes were monitored through resolution, with progress noted at least weekly, for the following: * 05/19/24 – Loss of friend/partner; * 06/20/24 – Rash on face; * 06/25/24 – COPD and change in mobility; * 07/08/24 – Left groin pain, enlarged and red right testicle; * 07/17/24 – “random bruising on hands”; * 08/11/24 – Resident self-reported fall without staff response; * 08/14/24 – Redness on right temporal mandibular joint; and * 08/28/24 – New urinary incontinence. The need to ensure actions or interventions for short-term changes of condition were documented and communicated to staff on each shift, and the changes of condition were monitored weekly through resolution was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations), Staff 3 (Regional Director of Operations) and Staff 17 (Regional RN) They acknowledged the findings. 4. Resident 1 was admitted to the facility in 05/2024 with diagnoses including unspecified dementia, urinary tract infections and weakness. Review of Resident 1’s record indicated the following deficiencies related to changes of condition: a. On 06/19/24, a home health RN documented the presence of “3 small open areas on the resident’s buttocks” and a “red rash/fungal area” on the upper torso. The facility’s last documentation on the status of the conditions was on 06/25/24. The facility failed to document on the progress of the conditions at least weekly until resolved. b. On 09/01/24 Resident 1 triggered for a significant weight loss of 7.68% body weight over the previous 90 days. In an interview on 09/09/24, Staff 7 (RCC) stated she contacted the resident’s daughter and asked her to provide a nutritional supplement. Staff 7 acknowledged the facility failed to document and communicate to staff what actions or interventions were needed for the resident in response to the weight loss and failed monitor whether the supplement had been provided and was being offered to the resident. The need to ensure the facility determined, documented and communicated to staff what actions or interventions were needed for a resident following a change of condition and that the facility documented monitoring of short term changes of condition at least weekly until the condition resolved was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations), Staff 3 (Regional Director of Operations) and Staff 17 (Regional RN) on 09/12/24. They acknowledged the findings. 5. Resident 4 was admitted to the facility in 05/2013 with diagnoses including congestive heart failure, edema and osteoarthritis. The resident had a history of chronic, recurring leg wounds. Review of Resident 4’s record indicated the following deficiencies related to changes of condition: a. On 07/16/24 Resident 4 reported swelling and pain to the lower right leg. The resident was sent to the local emergency department and returned with no new diagnosis or treatment recommendations. The facility documented on the status of the condition on 07/17/24. There were no documented actions or interventions provided to staff and the facility failed to document on the progress of the condition at least weekly until resolved. b. On 07/24/24 a MT documented the observation of a draining wound on the resident’s left big toe. There was no documented evidence the facility determined, documented and communicated to staff what actions or interventions were needed and the facility failed to document on the progress of the condition at least weekly until resolved. c. On 08/26/24 Resident 4 triggered for a significant weight loss of 8.15% body weight over the previous 90 days. There was no documented evidence the facility determined, documented and communicated to staff what actions or interventions were needed and the facility failed to monitor the condition. The need to ensure the facility determined, documented and communicated to staff what actions or interventions were needed for a resident following a change of condition and that the facility documented monitoring of short term changes of condition at least weekly until the condition resolved and monitored significant changes of condition was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations), Staff 3 (Regional Director of Operations) and Staff 17 (Regional RN) on 09/12/24. They acknowledged the findings.

1. Change of condition assessments for resident 1, 3, 4, 5 and 6 were completed and updated by RN. Service plans have been updated and interventions have been reviewed for effectiveness. Service plan includes clear direction to direct care staff on current interventions. 2. To prevent recurrence, staff will be reeducated on our alert charting guidelines, when to notify the RN and providing resident-specific actions or interventions to staff when a change of condition has been identified. 24 hour summary will be reviewed five days a week as part of daily standup meeting. On Mondays, the 72-hour summary will be reviewed to include review of all documentation from the weekend. When a change of condition is identified, the resident will be placed on alert charting which will then trigger a LN assessement, which will include any changes to the plan of care. The change of condition will be monitored until resolved or a new baseline is determined. When a change of condition is determined to be a significant change, the RN will be notified to complete a change of condition assessment and resident will be monitored until resolved or a new baseline is determined. Licenses nurses and Resident Care Coordinators reviewed regulations related to monitoring of change of condition, including effectiveness of interventions. 3. This system will be evaluated five days a week as part of stand up meeting and as needed when a change of condition occurs. 4. Executive Director and Licensed Nurses will be responsible for maintaining this system.

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 411-054-0040 (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 411-054-0040 (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 411-054-0040 (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:

1. Resident #7 was reassessed for all identified changes of condition identified during resurvey. Clear resolution was documented for any change of condition that had resolved, any change of condition still requiring monitoring was appropriately documented in weekly significant change monitoring updates or weekly skin checks. Resident’s service plan was reviewed and updated to include interventions to clearly address any care changes or monitoring required based on these changes of condition. 2. Staff have been reeducated on change of condition regulations, including what to do when a change of condition is identified, how to report changes of condition to the RN, the alert charting process, implementing ISPs to include resident specific interventions for monitoring change of condition and/or new interventions needed due to the change of condition, weekly skin monitoring system and significant change weekly updates. The communities Resident Care Coordinators and Licensed Nurses will complete the Oregon Care Partners course 'Compliance Series: Understanding Changes of Condition for Community-Based Care (CBC) Facilities in Oregon'. Clinical Stand-up will be held Monday-Friday, Monday the 72-hour report will be reviewed, and the 24-hour report will be pulled Tuesday-Friday to review documentation to identify changes of condition to verify residents have been placed on alert charting, ISPs have been entered, and RN has been notified of significant changes of condition. Alert charting will be audited weekly to review that interventions have been appropriately implemented and the effectiveness of those interventions, auditing will include ensuring clear resolution to all identified changes of conditions have been documented and/or service plan has been updated to include a change in the monitoring process other than alert charting. 3. This system will be monitored 5 days a week during clinical stand up and weekly. 4. Executive Director, Licensed Nurses

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

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 5 of 5 sampled residents (#s 1, 3, 4, 5 and 6) who experienced a significant change of condition. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 07/2022 with diagnoses including type 2 diabetes mellitus, diastolic (congestive) heart failure and chronic obstructive pulmonary disease. A review of the resident's clinical record dated between 06/13/24 and 08/30/24 identified the following: * A progress note on 6/14/24 stated “Resident returns to facility from [hospital] at 1605 …Resident does also have chronic wound to the left gluteal fold, open area is circular and is 0.5 cm in size;” * A skin integrity monitoring form was completed on 06/14/24 for “left buttock pressure” and electronically signed on 06/25/24 by a facility LPN; and * A skin integrity monitoring form was completed on 06/21/24 for “left gluteal fold open area” and electronically signed on 07/02/24 by a facility LPN. The noted skin impairment constituted a significant change in condition requiring an RN assessment. The RN assessment was completed on 09/10/24 while survey team was on site. The need to ensure an RN assessment was completed for all residents who experienced a significant change of condition was reviewed with Staff 9 (Regional RN) on 09/12/24 at 11:58 am, and Staff 1 (ED), Staff 2 (Vice President of Operations), and Staff 3 (Regional Director of Operations) on 09/12/24. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 05/2024 with diagnoses including unspecified dementia, urinary tract infections and weakness. Review of the weight record indicated Resident 1 experienced a loss of 9.8 pounds, or 7.68% body weight, between 06/01/24 and 09/01/24. This represented a significant change of condition for which an RN assessment of the weight loss was required. There was no documented evidence a facility RN completed an assessment which included findings, resident status and interventions made as a result of the assessment. During the survey, the resident was observed to request room trays for meals as s/he preferred to eat in his/her apartment. In an interview on 09/11/24 at 11:20 am, Staff 21 (Server) reported Resident 1 didn’t always eat breakfast and often requested half portions for lunch and dinner. In an interview on 09/12/24 at approximately 1:30 pm Resident 1 shared with this surveyor that s/he had not noticed any changes in appetite or weight, and that s/he believed his/her weight was fine. Resident 1’s current weight, requested on 09/11/24, was 118.2. This represented an increase of 3.4 pounds from the last weight of 114.8 pounds that was recorded on 09/05/24. The need to ensure an RN conducted and documented an assessment of a resident's significant change of condition was reviewed with Staff 1 (ED), Staff 2 (Vice President of Operations), Staff 3 (Regional Director of Operations) and Staff 17 (Regional RN) on 09/12/24. They acknowledged no RN assessment had been completed. 3. Resident 4 was admitted to the facility in 05/2013 with diagnoses including congestive heart failure, edema and osteoarthritis. The service plan noted the resident’s weight fluctuated due to edema in the lower legs. Review of the weight record indicated Resident 4 experienced a loss of 14.6 pounds, or 8.15% body weight, between 05/31/24 and 08/26/24. This represented a significant change of condition for which an RN assessment of the weight loss was required. There was no documented evidence a facility RN completed an assessment which included findings, resident status and interventions made as a result of the assessment. During the survey, the resident was observed to request room trays for meals as s/he preferred to eat in his/her apartment. In an interview on 09/10/24 at 2:10 pm, Resident 4 acknowledged eating less for two reasons: his/her dentures did not fit well which sometimes made chewing difficult and the meals were often unappetizing because the resident had been placed on an “easy to chew” texture diet following a choking incident at a meal. Resident 4’s current weight, requested on 09/11/24, was 165.8. This represented an increase of 1.4 pounds from the last weight that was recorded on 08/26/24. The need to ensure an RN conducted and documented an assessment of a resident's significant change of condition was reviewed with Staff 1 (ED), Staff 2 (Vice President of Operations), Staff 3 (Regional Director of Operations) and Staff 17 (Regional RN) on 09/12/24. They acknowledged no RN assessment had been completed. 4. Resident 3 was admitted to the facility in 07/2022 with diagnoses including chronic heart failure. Resident 3's weight record was reviewed during the survey and the following was noted: * 04/02/24 – 181 pounds; * 05/27/24 – 167 pounds; * 06/02/24 – 166.6 pounds; * 07/02/24 – 165.9 pounds; and * 08/31/24 – 182.6 pounds. Review of the weight record indicated Resident 3 experienced a loss of 15.1 pounds, or 8.34 % body weight, between 04/01/24 and 07/02/24. This represented a significant change of condition for which an RN assessment of the weight loss was required. There was no documented evidence a facility RN completed an assessment which included findings, resident status and interventions made as a result of the assessment. During the survey, the resident was observed in the dining room for meals and able to eat independently. In an interview on 09/10/24 at approximately 9:13 am Resident 3 shared with this surveyor that s/he had not noticed any changes in appetite. The need to ensure an RN conducted and documented an assessment of a resident's significant change of condition was reviewed with Staff 1 (ED) and Staff 2 (Vice President of Operations) on 09/12/24. They acknowledged no RN assessment had been completed. 5. Resident 6 was admitted to the facility in 06/2017 with diagnoses including chronic obstructive pulmonary disease, chronic pain, anxiety, and major depressive disorder. Review of the resident’s record indicated a left gluteal pressure ulcer was identified between 03/2024 and 04/2024. The new pressure ulcer constituted a significant change of condition for which an RN assessment was required. On 09/12/24 at 11:20 am, Staff 9 (Regional RN) stated an RN assessment had not been completed which documented findings, resident status, and interventions made as a result of the assessment. The need to ensure a timely RN assessment was completed for residents who experienced a significant change of condition was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations), Staff 3 (Regional Director of Operations) and Staff 17 (Regional RN). They acknowledged the findings.

1. Significant change of condition assessments for resident 1, 3, 4, 5 and 6 were completed and updated by RN. RN conducted audit for all residents to determine if any current change of conditions required an RN assessment. 2. To prevent recurrence, staff will be reeducated on change of condition reporting and when to notify the RN. An RN has been hired for the Director of Health Services position to provide consistency of resident care. 24 hour summary will be reviewed five days a week as part of daily standup meeting. On Mondays, the 72-hour summary will be reviewed to include review of all documentation from the weekend. When a change of condition is identified, the resident will be placed on alert charting which will then trigger a LN assessement, which will include any changes to the plan of care. The change of condition will be monitored until resolved or a new baseline is determined. When a change of condition is determined to be a significant change, the RN will be notified to complete a change of condition assessment and resident will be monitored until resolved or a new baseline is determined. The health services team have been reeducated on the RN requirements related to change of condition. 3. This system will be evaluated five days a week as part of stand up meeting and as needed when a change of condition occurs. 4. Executive Director and Licensed Nurses will be responsible for maintaining this system.

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

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed timely for 2 of 3 sampled resident (#s 5 and 8) who experienced weight loss. This is a repeat citation. Findings include, but are not limited to: 1. Resident 8 moved into the facility in 03/2021 with diagnoses including prostate cancer. The resident’s progress notes, dated 12/31/24 through 03/16/25, and weight records, dated 10/29/24 through 01/23/25, were reviewed. Resident 8 and staff were interviewed. The following weights were recorded by the facility: * 10/29/24: 169 pounds; * No weight documented for 11/2024; * 12/19/24: 157 pounds; * 01/23/25: 154.8 pounds; and * No weight documented for 02/2025. The facility weighed the resident during the survey. On 03/19/25 at 1:34 pm, Resident 8 weighed 158.2 pounds. Between 10/29/24 and 01/23/25, the resident had a 14.2 pound weight loss, or an 8.4% loss in total body weight. The weight loss represented a significant change of condition. There was no documented evidence the facility RN conducted a timely assessment which included documentation of findings, resident status, and interventions made as a result of the assessment. An interview with Staff 17 (Vice President of Clinical Services) on 03/20/25 at 10:07 am confirmed an RN assessment had not been completed when the weight loss was identified in the electronic system on 12/19/24. The need to ensure a timely RN assessment was completed for residents who experienced a significant change of condition was discussed with Staff 3 (Regional Director of Operations), Staff 17, and Staff 22 (ED) on 03/21/25 at 1:11 pm. They acknowledged the findings. 2. Resident 5 moved into the facility in 10/2019 with diagnoses including chronic obstructive pulmonary disease. The resident’s progress notes, dated 12/19/24 through 03/18/25, and weight records, dated 11/11/24 through 03/19/25, were reviewed. Resident 5 and staff were interviewed. The following weights were recorded by the facility: * 11/11/24: 305.2 pounds; * 02/04/25: 305 pounds; * 02/18/25: 302 pounds; and * 03/04/25: 288.4 pounds. The resident had a weight gain following significant weight loss and did not lose further weight. Between 02/04/25 and 03/04/25, the resident had a 16.6 pounds weight loss, or an 5.44% loss in total body weight. The weight loss represented a significant change of condition. The facility completed a significant change in condition assessment on 03/04/25. The assessment noted the resident experienced weight loss. However, there was no documented evidence of the assessment findings, resident’s status and interventions implemented as a result of the assessment. An interview with Staff 17 (Vice President of Clinical Services) on 03/21/25 at 11:33 am reviewed the assessment and confirmed there were no documented findings, resident status or interventions resulting from the assessment related to the resident’s weight loss. The need to ensure a RN assessment was completed for residents who experienced a significant change of condition was discussed with Staff 3 (Regional Director of Operations), Staff 17, and Staff 22 (ED) on 03/21/25 at 12:47 pm. They acknowledged the findings.

1. RN conducted significant change assessments on both residents #5 and #8, these assessments were reviewed by VP of Clinical Operations to ensure all necessary components including status of resident, conclusion based on assessment findings, interventions implemented and monitoring plan. Service plans for resident #5 and #8 have been reviewed and any changes needed identified by the RN significant change of condition assessments have been implemented. 2. Staff have been reeducated on change of condition regulations, including significant weight change parameters and timelines for starting the RN assessment. The communities Licensed Nurses will complete the NurseLearn Course 'Significant Change of Condition: Weight Changes'. Weights entered PCC will be reviewed during Clinical Stand-Up Monday-Friday to ensure timely identification of weight changes that are considered a Significant Change. Weekly the Health Services team will review residents that are on Significant Change weight monitoring to verify interventions have been implemented and are effective, service plan will be adjusted if interventions are identified as not effective. The change of condition will be monitored until resolution, or it is determined resident has reached a new baseline. The Health Services Team will audit completion of monthly weights by the 15th of every month. 3. This system will be monitored 5 days a week during clinical stand up and weekly. 4. Executive Director, Licensed Nurses and Resident Care Coordinators

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

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

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility, for 1 of 2 sampled residents (#6) whose MARs and Controlled Substance Disposition logs were reviewed. Findings include, but are not limited to: Resident 6 was admitted to the facility in 06/2017 with diagnoses including chronic obstructive pulmonary disease, chronic pain, anxiety, and major depressive disorder. During the acuity interview on 09/09/24, the resident was identified as receiving hospice services and was administered pain and anxiety medications as needed. The resident's 08/01/24 through 09/09/24 MARs and Controlled Substance Disposition Log were reviewed and following was identified: a. Resident 6 had signed physician orders for morphine sulfate powder (morphine sulfate) 0.8 mL to be administered every hour for pain as needed. * The Controlled Substance Disposition Log documented the morphine was administered on 151 occasions; however, the MAR was initialed as administered on 140 occasions. b. Resident 6 had signed physician orders for lorazepam 0.5 mg to be administered every two hours as needed for anxiety. * The MAR and Controlled Substance Disposition Log showed multiple discrepancies. On 09/12/24 at 2:48 pm, inconsistencies between the MAR and Controlled Substance Disposition logs were reviewed with Staff 1 (ED), Staff 2 (Vice President of Operations), Staff 3 (Regional Director of Operations) and Staff 17 (Regional RN) They reviewed the documentation and acknowledged the discrepancies. The need to ensure the facility had a system for tracking controlled substances was discussed with Staff 1, Staff 2, Staff 3, and Staff 17 on 09/12/24. They acknowledged the findings.

1. An audit was completed on the narcotics for Resident #6 and discrepancies were investigated. Med techs were coached on proper controlled substance and medication pass procedures. Controlled substance audit for all residents was conducted. 2. Retraining completed with all med techs on controlled substance procedure and tracking. Weekly controlled subtsance audits completed for accuracy. Any identified concerns will be addressed. 3. Weekly 4. Executive Director, Health Services Director, Resident Care Coordinator

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed, and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications the facility was responsible for administering for 1 of 5 sampled residents (#6) whose records were reviewed. Findings include, but are not limited to: Resident 6 was admitted to the facility in 06/2017 with diagnoses including chronic obstructive pulmonary disease, chronic pain, anxiety, and major depressive disorder. The resident's 08/01/24 to 09/09/24 MARs and physician orders dated 09/10/24 were reviewed, and the following was identified: a. There were multiple blanks on the MAR for the following medications: * Albuterol-ipratropium (for shortness of breath); * Barrier cream (for skin protection); and * Nebulizer treatments (for shortness of breath). b. The following signed physician orders were not included on the MAR and were not being administered: * Folic acid (for anemia deficiency); and * Ibuprofen (for mild pain). c. There were no signed, written orders in the resident’s record for the following treatments on the MAR: * Oxygen via nasal cannula, liter use; * Use of continuous positive airway pressure machine; and * Compression stockings. On 09/12/24 at 8:45 am, Staff 2 (Vice President of Operations) stated she was aware the medication and treatment were not administered as prescribed, and several orders were not included in the resident’s record. The need to ensure orders were carried out as prescribed and written signed physician or other legally recognized practitioner orders were documented in the resident's record was discussed on 09/12/24 with Staff 1 (ED), Staff 2, Staff 3 (Regional Director of Operations) and Staff 17 (Regional RN). They acknowledged the findings.

1. Obtained updated physician orders for Resident #6, verified all medications were on hand and MAR audit completed for accuracy. 2. All med techs were reeducated on Medication policies and procedures. Training provided to Health Services team on weekly MAR audits. 24/72 hour report reviewed daily to indentify that all medications have been reordered timely. 3. Weekly 4. Executive Director, Director of Health Services, Resident Care Coordinator

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure physician or other legally recognized practitioner orders were carried out as prescribed for 2 of 3 sampled residents (#s 5 and 7) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 7 moved into the facility in 07/2021 with diagnoses including Parkinson’s disease with dyskinesia, chronic diastolic heart failure, and vertigo. The resident's 12/01/24 through 03/19/25 MARs and physician’s orders were reviewed, and the following was identified: a. The resident had an order for daily weights. From 12/01/24 through 02/28/25, weights were not documented on 36 occasions, including periods of up to eight consecutive days. b. The physician’s order for daily weights included to notify the physician of three pound weight changes in one day and five pound weight changes in one week. There was no documented evidence the physician was notified of weight changes outside of the parameters given on multiple occasions. c. The following physician’s orders were not administered as prescribed: * Tizanidine (for tremors) – on 11 occasions from 01/03/25 through 01/13/25; * Benefiber (for constipation) – on nine occasions from 02/11/25 through 02/20/25; and * Culturelle (supplement) – on 33 occasions from 02/01/25 through 02/28/25. On 03/21/25 at 12:42 pm, Staff 17 (Vice President of Clinical Services, RN) confirmed there was no additional documentation. The need to ensure orders were carried out as prescribed, was reviewed on 03/21/25 at 1:37 pm with Staff 3 (Regional Director of Operations), Staff 17 and Staff 22 (ED). They acknowledged the findings.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure physician or other legally recognized practitioner orders were carried out as prescribed for 2 of 3 sampled residents (#s 5 and 7) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 7 moved into the facility in 07/2021 with diagnoses including Parkinson’s disease with dyskinesia, chronic diastolic heart failure, and vertigo. The resident's 12/01/24 through 03/19/25 MARs and physician’s orders were reviewed, and the following was identified: a. The resident had an order for daily weights. From 12/01/24 through 02/28/25, weights were not documented on 36 occasions, including periods of up to eight consecutive days. b. The physician’s order for daily weights included to notify the physician of three pound weight changes in one day and five pound weight changes in one week. There was no documented evidence the physician was notified of weight changes outside of the parameters given on multiple occasions. c. The following physician’s orders were not administered as prescribed: * Tizanidine (for tremors) – on 11 occasions from 01/03/25 through 01/13/25; * Benefiber (for constipation) – on nine occasions from 02/11/25 through 02/20/25; and * Culturelle (supplement) – on 33 occasions from 02/01/25 through 02/28/25. On 03/21/25 at 12:42 pm, Staff 17 (Vice President of Clinical Services, RN) confirmed there was no additional documentation. The need to ensure orders were carried out as prescribed, was reviewed on 03/21/25 at 1:37 pm with Staff 3 (Regional Director of Operations), Staff 17 and Staff 22 (ED). They acknowledged the findings. 2. Resident 5 moved into the facility in 10/2019 with diagnoses including chronic obstructive pulmonary disease. The resident's 03/01/25 through 03/19/25 MARs and physician’s orders were reviewed, and the following was identified: The following medications were not administered physician’s orders: * The resident had an order for Flomax (for urinary retention) daily. The MAR showed on 03/04/25, the medication was not administered because it was unavailable. * The resident had an order for Lidocaine patch (for pain) daily. The MAR showed from 03/04/25 to 03/09/25, on six occasions, the medication was not administered because it was unavailable. * The resident had an order for Melatonin (for insomnia) daily. The MAR showed on two occasions, 03/03/25 and 03/04/25, the medication was not administered because it was unavailable. * The resident had an order for Fluticasone inhaler (for chronic obstructive pulmonary disease) two times daily. The MAR showed on two occasions, 03/0f4/25 and 03/07/25, the medication was not administered because it was unavailable. * The resident had an order for Clotrimazole 2% vaginal cream (for infection) daily for three consecutive days. The MAR showed the medication was administered only two days, not three days as prescribed. The need to ensure orders were carried out as prescribed, was reviewed on 03/21/25 at 12:47 pm with Staff 3 (Regional Director of Operations), Staff 17 (Vice President of Clinical Services), and Staff 22 (ED). They acknowledged the findings

1. MAR audits completed for resident #5 and #7, audit included verification that all active orders were on hand and available for administration and all required notifications had been made per provider instructions. 2. Reeducation provided to all medication techs on procedures for assisting with medication, reordering medications, and following physician orders. Audit completed on communities’ current re-ordering process to ensure all residents using pharmacies that provide cycle fill are appropriately receiving medications from those pharmacies. During daily Clinical Stand up the 72-hour report will be reviewed on Monday and the 24-hour report Tuesday-Friday to review exceptions documented for any medications and ensure they are followed up on timely. MAR audits will be conducted weekly to verify medications are being administered correctly and notifications are being conducted per provider instructions. 3. This system will be monitored 5 days a week during clinical stand up and weekly. 4. Executive Director, Licensed Nurses and Resident Care Coordinators

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

OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications were evaluated upon move-in and at least quarterly thereafter to assure the residents’ ability to safely self-administer medications for 2 of 2 sampled residents (#s 3 and 5) who were reviewed for self-administration. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 07/2022 with diagnoses including type 2 diabetes mellitus, diastolic (congestive) heart failure and chronic obstructive pulmonary disease. During the acuity interview on 09/09/24, Resident 5 was identified as self-administering some of his/her medications. During the interview on 09/10/24 the resident indicated s/he was administering oxygen as needed overnight for shortness of breath, eye drops and insulin subcutaneously sometimes under the supervision of the MT. This was confirmed by Staff 12 (MT) in an interview on 09/10/24 and observed by the surveyor on 09/11/24. Review of Resident 5’s medical records revealed there was no documented evaluation of Resident 5's ability to safely self-administer medications. In an interview on 09/10/24 at 12:35 pm, Staff 2 (Vice President of Operations) was unable to locate a copy of the self-administration evaluation, and an evaluation was completed on 09/10/24 by the facility RN. The need to ensure residents who chose to self-administer their medications were evaluated upon move-in and at least quarterly thereafter to assure the residents’ ability to safely self-administer medications was reviewed with Staff 1 (ED), Staff 2, and Staff 3 (Regional Director of Operations) on 09/12/24. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 07/2022 with diagnoses including chronic heart failure. On 09/10/24 at 9:15 am, Resident 3 reported s/he managed their own medications with family assistance. During the interview, a pill box was observed in the resident’s room. The resident reported s/he took the medications three times daily. Review of Resident 3’s record indicated the following: * There was no current evaluation of the resident’s ability to safely self-administer the medications; and * The most recent self-administration evaluation was dated 12/06/23 indicating the resident’s ability to safely self-administer had not been evaluated quarterly as required. On 09/10/24, Staff 2 (Vice President of Operations) confirmed no current evaluation had been completed. Staff 9 (Regional RN) completed an evaluation on 09/10/24. On 09/12/24, the failure to evaluate the resident's ability to self-administer medications quarterly was discussed with Staff 1 (ED), Staff 2 and Staff 3 (Regional Director of Operations). They acknowledged the findings.

1. Self medication assessments were completed for residents 3 and 5. Audit completed for all self medication residents to ensure they have received a timely assessment. 2. Training completed with Health Services Team related to requirements for residents to self administer medications. Training completed on how to make sure the self medication triggers quarterly in Point Click Care. LN will conduct self medication assessment at time of move-in and quarterly and upon change of condition. 3. Assessments coming due are reviewed during weekly clincial meeting. Self Medication assessments completed at time of move-in, quarterly and when there is a change of condition. 4. Executive Director and Health Services Director

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

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have sufficient direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: The current facility staffing plan and Acuity Based Staffing Tool (ABST) were reviewed, and interviews with residents were conducted. The following was revealed: * During an interview on 09/11/2024, Resident 5 stated, “You have to wait for a long time for them to respond”; * The review of the Call Light response log from 08/25/24 through 09/09/24 indicated during every day shift there was at least one occasion when the response time exceeded 25 minutes, and eight day shifts with at least five occasions when the response time exceeded 25 minutes; and * The facility’s staffing schedule for the weeks of 08/25/24, 09/01/24, and 09/08/24 did not reflect the amount of direct care staff hours required by the facility’s ABST tool output. The need for the facility to have sufficient direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident was reviewed with Staff 1 (ED), Staff 2 (Vice President of Operations), and Staff 3 (Regional Director of Operations) on 09/12/24. They acknowledged the findings.

1. Comprehensive audit of all resident service plans completed. ABST times adjusted according to current resident needs. Increased staffing to meet resident needs based off the ABST. Training completed with all direct care staff in regard to call light response times and expectation to answer promptly. 2. ABST will be updated prior to move-in, upon move-in, 30-day review, quarterly review and when a change of condition occurs. Staffing will be adjusted based off ABST whenever there is a change. Review of call times during stand up, follow up with staff when there is non-complaince with expectation of prompt response. 3. ABST is reviewed weekly and as needed based on new move-ins, 30-day, quarterly and when there is a change of condition. Staffing adjusted accordingly. Call times are reviewed during stand up meeting five days a week. 4. Executive Director, Health Services Director

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident including fire evacuation standards. This is a repeat citation. Findings include, but are not limited to: The current facility staffing plan, and the fire life and safety documentation were reviewed. The following was identified during the entrance conference and acuity interview on 03/19/25: * The facility was home to 57 residents at the time of survey; * The facility consisted of a three-story building; * The second floor had one resident who required two staff members to assist with transfers as needed; and * The third floor had six residents who required two staff members to assist with transfer, including four residents who needed the use of a Hoyer lift. The posted facility staffing requirement indicated for the following: * Day shift: Four direct caregiving staff and two Medication Technicians; * Evening shift: Four direct caregiving staff and two Medication Technicians; and * Night shift: Two direct caregiving staff and one Medication Technician. The facility had multiple residents residing on the second and third floors who regularly required a two staff assist for transfers, posing a potential risk for delayed evacuation during overnight hours due to insufficient overnight staff to meet scheduled and unscheduled care needs in accordance with evacuation standards. The need for the facility to have sufficient direct caregiving staff to meet the 24-hour scheduled and unscheduled needs of each resident was reviewed with Staff 3 (Regional Director of Operations), Staff 17 (Vice President of Clinical Services) and Staff 22 (ED) on 03/21/25. They acknowledged the findings.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by:

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident including fire evacuation standards. This is a repeat citation. Findings include, but are not limited to: The current facility staffing plan, and the fire life and safety documentation were reviewed. The following was identified during the entrance conference and acuity interview on 03/19/25: * The facility was home to 57 residents at the time of survey; * The facility consisted of a three-story building; * The second floor had one resident who required two staff members to assist with transfers as needed; and * The third floor had six residents who required two staff members to assist with transfer, including four residents who needed the use of a Hoyer lift. The posted facility staffing requirement indicated for the following: * Day shift: Four direct caregiving staff and two Medication Technicians; * Evening shift: Four direct caregiving staff and two Medication Technicians; and * Night shift: Two direct caregiving staff and one Medication Technician. The facility had multiple residents residing on the second and third floors who regularly required a two staff assist for transfers, posing a potential risk for delayed evacuation during overnight hours due to insufficient overnight staff to meet scheduled and unscheduled care needs in accordance with evacuation standards. The need for the facility to have sufficient direct caregiving staff to meet the 24-hour scheduled and unscheduled needs of each resident was reviewed with Staff 3 (Regional Director of Operations), Staff 17 (Vice President of Clinical Services) and Staff 22 (ED) on 03/21/25. They acknowledged the findings.

1.Fire Marshall meeting and walk through was completed on 3/2/2025. Evacuation plan was reviewed and staffing plan was reviewed. Evauation plan with staffing plan was submitted to Fire Marshall and approved on 4/10/2025. 2. In the event of a fire and we need to evacuate the area the following plan is in place. We will evacuate the resident who’s apartment is effected, the apartments to the side and above or below as well as across the hall. We will move these residents to the area of rescue on the other side of the fire doors furthest away from the effected area. 3.For residents that are not able to get down the stairs by ambulating we will assist them by utilizing the draw sheet method. Hillsboro Fire will also assist with transferring residents out of the community as Safety first then fire is the process that they as well follow. 4.Fire drill with evacuation was completed on the third floor with a resident that is of highest care 4/10/2025. ED and RCC will monitor staffing daily to assure adequte staffing for scheduled and unscheduled needs. ED and Maintenance Director will monitor Fire Life Safety every other month.

OAR 411-054-0037 (1)(2)(a)(c) Acuity Based Staffing Tool: Development (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING. Facilities must select and implement an acuity-based staffing tool (ABST) that is technology-based for determining appropriate staffing levels. Individual resident needs and care elements must be the primary consideration when developing and maintaining an ABST. Regardless of the ABST adopted, all requirements set forth in this rule and OAR 411-054-0034 (Resident Move in Evaluation) must be met. Facilities shall: (a) Select and implement the Department?s developed ABST or submit a proprietary ABST to the Department for approval as outlined in paragraph (2) of this rule. (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident?s legal representative, or the Long-Term Care Ombudsman. (2) PROPRIETARY ABST. A facility that chooses to use a proprietary ABST must implement a Department-approved ABST that meets this rule. (a) REQUIRED ELEMENTS. The proprietary ABST the facility adopts must meet the following requirements: (A) Address and document all individual ABST care elements outlined in paragraph (3) of this rule. (B) When calculating total time, the ABST must include the care elements for each resident and staff time needed to complete each individual care element. (C) Ensure the ABST can produce a report that identifies all residents currently residing in the facility, the care elements for each of the residents, and the staff time required to complete each care element for each resident. (D) Ensure the ABST can present the total time, in minutes, required to meet the scheduled needs for all residents, 24 hours a day, seven days a week, preferably per shift, per day. (E) Identify the date the resident?s ABST evaluation was last completed. (F) If applicable, determine ABST time for both residents on a Specific Needs Contract and residents not on a Specific Needs Contract to build posted staffing plans as outlined in this rule. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation. Findings include, but are not limited to: The facility's ABST was reviewed and discussed with Staff 1 (ED) on 09/11/24 at 3:35 pm and with Staff 2 (Vice President of Operations) at 3:40 pm. The facility had implemented the Department’s ABST tool. The following was identified: * Multiple residents’ individual ABST data had not been reviewed at least quarterly; and * The time required to complete various ADLs was not accurate for 4 of 6 sampled residents (#s 2, 3, 4 and 6). The need to implement an ABST which met the regulation was discussed with Staff 1, Staff 2, and Staff 3 (Regional Director of Operations) on 09/12/24 at 10:40 am. They acknowledged the findings.

1. ABST updated for resident #2,3,4 and 6. A comprehensive audit of all resident service plans completed. ABST times adjusted according to current resident needs. 2. ABST will be updated prior to move-in, upon move-in, 30-day review, quarterly review and when a change of condition occurs. Team have been trained to go into the ABST and hit save upon the review in order to show it has been updated when there are no changes. 3. ABST is reviewed weekly and as needed based on new move-ins, 30-day, quarterly and when there is a change of condition. 4. Executive Director and Health Services Director

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

OAR 411-054-0070 (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 document that 2 of 2 sampled direct care staff (#s 11 and 19) demonstrated knowledge and performance in all required areas within 30 days of hire. Findings include, but are not limited to: Training records were reviewed on 09/11/24 at 10:10 am with Staff 6 (Director of Business Services) and Staff 20 (Finance Manager). Staff 11 (CG) was hired 04/30/24 and Staff 19 (CG) was hired 07/19/24. The facility was unable to provide documented evidence Staff 11 and 19 had demonstrated competency in all required job duties within 30 days of hire. The need to ensure all direct care staff have documentation of demonstrated knowledge and performance in all required areas within 30 days of hire was reviewed with Staff 6 and 20 on 09/11/24 and with Staff 1 (ED), Staff 2 (Vice President of Operations), Staff 3 (Regional Director of Operations) and Staff 17 (Regional RN) on 09/12/24. They acknowledged the lack of documentation of staff competency.

1. Competencies and training were completed for staff #11 and #19. Audit completed for all staff and verified competencies and training are up to date. 2. Business Office Manager will maintain current training grid and ensure completion of all new hire and annual training timely. The Resident Care Coordinator is responsible to have new hires complete their comptencies within 30 days of hire. 3. Monthly review to ensure all training and competencies are completed and up-to-date. 4. Executive Director, Business Office Manager, Resident Care Coordinator

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

OAR 411-054-0090 (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 conduct fire drills in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to: Six months of fire drill records were requested and reviewed on 09/09/24. The following was identified: a. Fire drills were not conducted every other month in accordance with OFC. b. The documented fire drills conducted on 06/05/24 and/or 08/29/24 lacked the following components: * Escape route used; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Number of occupants evacuated; and * Evidence of alternate routes used. On 09/09/24 at 2:33 pm, Staff 4 (Director of Maintenance) confirmed residents were evacuated once during fire drills conducted in the last six months and staff were unable to identify problems encountered. The need to ensure fire drills were conducted in accordance with the Oregon Fire Code was discussed with Staff 1 (ED), Staff 2 (Vice President of Operations), and Staff 4 on 09/09/24. They acknowledged the findings.

1. Provided training to Maintenance Director on the requirement to document Fire Drills in Assisted Living every other month and on the requirements for staff training on alternating months. An assisted living fire drill has been completed with appropriate escape route and documentation of any residents who refused to participate. The drill included the number of people who evacuated. 2. Provided Maintenance Director with the appropriate form to use to document a fire drill to include all required components: who refused, who participated, alternative routes. This form is kept in TELs which is the software used to track maintenance tasks is reviewed monthly between the Executive Director and Maintenance director. 3. Fire Drills will occur every other month and staff training will occur on alternating months. TELs will be reviewed monthly. 4. Executive Director and Maintenance Director are responsible for maintaining this system.

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 411-054-0105 (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 411-054-0105 (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: Facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C270, C280, C303 and C360.

Please see plan of correction for C270, C280, C303 and C360

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 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (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 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. An ALF 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 must 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 09/09/24. The following areas needed repair: First Floor: * Elevator frame was chipped. Second Floor: * Elevator frame was chipped; * Wall next to Room 209 was chipped and gouged; * Room 212 door was chipped and gouged; * Room 212 walls were chipped, dinged, gouged, scratched and scuffed; * The baseboard near the laundry room had water damage; * Laundry room door and door frame were chipped, dinged and gouged; * Medication room door and door frame were chipped and gouged; and * The "Fire Damper Access" vent had a layer of dust. Third Floor: * Elevator frame was chipped; * The "Fire Damper Access" vent had a layer of dust; * A ceiling vent near Room 319 had a layer of dust and a part of the vent was missing; * Inside of the oven in the activity room had accumulated brown and black matter; * Laundry room door and door frame were chipped, dinged and gouged; * Inside cabinet underneath of sink in the laundry room had black and brown matter; * Inside cabinets throughout the laundry room had brown matter; * The backsplash of the sink in the laundry room had cracks; * A shelf in the window in the laundry room had water damage; * The ceiling in the laundry room had multiple holes; * Room 312 door was chipped and gouged; and * A hopper sink in the storage room had accumulated layers of dust and brown matter inside the sink. On 09/10/24 and 09/12/24, the areas in need of repair were reviewed Staff 1 (ED), Staff 2 (Vice President of Operations), Staff 3 (Regional Director of Operations) and Staff 4 (Director of Maintenance). Staff acknowledged the findings.

1. Repaired first, second, third floor chipped elevator frame. Repaired chips and grout in hallway near apartment 209. Repaired doorframe for apartment 209 and 212. Repaired 212's walls. 2nd floor laundry room baseboards were replaced and 2nd and 3rd floor laundry room doorframe were repaired. Medication room door repaired. Fire dampners were cleaned. Ceiling vent near 319 was cleaned. Activity room oven was cleaned. Cleaned out below 2nd and 3rd floor laundry room sink. 3rd floor laundry room backsplash repaired. 3rd Floor laundry room shelves replaced. 3rd floor laundry room holes in ceiling were patched and repaired. Room 312 door repaired. Hopper sink cleaned out. 2. Facility will conduct weekly audits to identify concerns with general building maintenance and cleanliness. Provided training and expectation to housekeepers and care staff to report environmental needs. Any concerns noted during audit will be addressed. 3. Reviewing audits monthly to ensure compliance. 4. Executive Director and Maintenance Director

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (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 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. An ALF 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 must be kept clean and in good repair. This Rule is not met as evidenced by: