Print Inspection: RL000633

OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. Findings include, but are not limited to: During the first re-visit to the facility’s re-licensure survey, conducted 06/02/25 through 06/04/25, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of repeat citations and the addition of new citations. Refer to the deficiencies in the report.

• The Administrator immediately conducted a comprehensive review of all prior and current citations to identify breakdowns in oversight, follow-through, and internal accountability. • An emergency leadership meeting was held to review regulatory expectations, the role of each department head, and the urgency of implementing lasting corrective measures. • Corrective actions for all open citations were re-evaluated and re-implemented with closer monitoring and clearer staff responsibilities. • Communication was made with the DHS Licensing Specialist to acknowledge the citation and provide assurance of improved oversight systems moving forward. I have signed a letter of agreement with the Oregon Department of Human Services to complete the reccommended training requirements: Change of conditions and medication systems. In the letter of agreement DHS asks that I provide documentated proof of the completed trainings by July 15th 2025. 2. Systemic Changes to Prevent Recurrence a. Administrative Oversight System • A Compliance Oversight Dashboard was implemented and is reviewed weekly by the Administrator. This dashboard tracks: o Open and past-due corrective actions o Quality assurance metrics (e.g., care plan accuracy, documentation compliance, medication errors) o Resident care concerns and staff follow-up • A Corrective Action Tracking Log has been adopted to monitor citation-specific plans, assigned personnel, deadlines, and verification steps. b. Strengthened Leadership Roles and Accountability • All department heads now submit weekly status reports to the Administrator outlining completed tasks, outstanding issues, and any barriers to compliance. • Leadership performance evaluations have been updated to include compliance outcomes as a key performance indicator (KPI). c. Enhanced Quality Assurance Program • The QA Committee has been restructured to meet biweekly instead of monthly and includes: o Administrator o Resident Care Coordinator (RCC) o Medication Supervisor o Maintenance and Housekeeping Leads o Staff Development Coordinator • Each QA meeting will focus on: o Review of new and past deficiencies o Resident concerns, incidents, and staff reports o Progress on current POCs o Ongoing regulatory review and readiness d. Training and Communication • A mandatory Administrative Oversight and Compliance Training was completed by all department heads, emphasizing: o Oregon ALF regulations and the purpose of each rule o Preventing repeat deficiencies through continuous improvement o Leadership responsibility in regulatory readiness • Monthly all-staff in-services will now include updates on compliance goals and outcomes to ensure transparency and accountability across all departments. 3. Monitoring and Quality Assurance • Weekly Compliance Rounds: The Administrator or designee will conduct weekly walk-throughs and documentation reviews with department heads to verify sustained implementation of corrective actions. • Monthly Internal Audit: A rotating team will perform monthly audits on key compliance areas, including care planning, medication management, documentation, and environmental safety. • Resident and Family Feedback: Quarterly resident/family satisfaction surveys will include questions related to care quality and responsiveness to concerns, which will be reviewed by the QA Committee. 4. Responsible Party • Administrator and RCC – Directly responsible for the implementation of oversight systems and ensuring all POCs are completed and monitored. • Department Heads – Accountable for implementing corrective actions within their departments and reporting progress. • QA Committee – Oversees continuous monitoring and internal accountability systems.

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

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to report an injury of unknown cause to the local APD office as suspected abuse unless an immediate facility investigation reasonably concluded and documented that the physical injury was not the result of abuse, for 3 of 3 sampled residents (#s 1, 2 and 4) with documented injuries of unknown cause. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 09/2015 with diagnoses including hemiplegia and hemiparesis following a cerebrovascular accident affecting the dominant side, and osteoporosis. Review of the record indicated staff documented the discovery of the following injuries: * 07/17/24: Dark purple discoloration on right bicep; * 08/27/24: Discoloration on left hand; * 09/27/24: Discoloration on right arm; and * 09/30/24: Red and purple discoloration on left hand. There was no documented evidence the facility either immediately investigated the injuries and reasonably concluded and documented the injuries were not the result of abuse or reported the injuries to the local APD office as suspected abuse. The injuries were reviewed with Staff 1 (ED) and Staff 2 (RCC) on 10/10/24 at 2:00 pm. They acknowledged no investigations were conducted which concluded the injuries were not the result of abuse and the injuries were not reported to the local APD office as suspected abuse. The surveyor provided a copy of the applicable Oregon Administrative Rule (OAR) and instructed them to self-report the identified injuries to the local APD office. Confirmation the injuries were reported was received on 10/15/24. 2. Resident 4 was admitted to the facility in 12/2023 with diagnoses including history of broken back, low back pain and osteoporosis. Review of the record indicated staff documented the discovery of the following injuries: * 07/25/24: Red/purple discoloration on top of left wrist; * 09/03/24: Scratches on right shoulder; and * 10/07/24: Discoloration on left forearm. There was no documented evidence the facility either immediately investigated the injuries and reasonably concluded and documented the injuries were not the result of abuse or reported the injuries to the local APD office as suspected abuse. The injuries were reviewed with Staff 1 (ED) and Staff 2 (RCC) on 10/10/24 at 2:00 pm. They acknowledged no investigations were conducted which concluded the injuries were not the result of abuse and the injuries were not reported to the local APD office as suspected abuse. The surveyor provided a copy of the applicable Oregon Administrative Rule (OAR) and instructed them to self-report the identified injuries to the local APD office. Confirmation the injuries were reported was received on 10/15/24. 3. Resident 2 was admitted to the facility in 2023 and was assisted by staff for several ADL care needs. His/her clinical record revealed the following: * On 08/20/24, staff documented that the top of the resident’s left hand had a "small area that was open and bleeding”; and * On 10/02/24, staff documented that the resident was found with a "scratch on [his/her] right wrist." There was no documented evidence the facility immediately investigated and documented that the injuries were not the result of abuse or neglect. The facility did not report the injuries to the local APD office as suspected abuse/neglect. The need to ensure injuries of unknown cause were investigated promptly or reported if necessary was discussed with Staff 1 (ED) and Staff 2 (RCC) on 10/10/24 at 1:45 pm. They acknowledged the facility had not investigated to rule out abuse/neglect. The surveyor directed Staff 1 to self-report the incidents. Verification that the facility had reported the incidents to the local APD office was received on 10/15/24.

We have updated our reporting system for injuries of unknown cause, alerting the RN, RCC, and administrator of the injuries. Using the system to track and investigate any injuries and allowing us to track and report as needed. This has been corrected by, we did self report to APS for the incidents for Residents 1, 2 and 4. The RN, RCC and Administrator will be responsible in making sure that this rule is met and followed. This will be checked weekly for any followup that we need to do. If it is determined that it is an injury of unknown cause the RN, RCC, or the Administrator will do a self report to APS.

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, the facility failed to immediately investigate incidents relating to falls and injuries of unknown cause to rule out abuse or suspected abuse, and notify the local SPD office if abuse could not reasonably be ruled out, for 2 of 2 sampled residents (#s 5 and 6) whose records were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 05/2023 with diagnoses including hypertension, arthritis, and cognitive impairment. Review of the resident's progress notes, dated 03/01/25 through 06/02/25, and incident reports revealed the following: * 03/06/25: “bruise on left hip and another one on left arm down by elbow”; * 03/20/25: “large brownish/green discoloration on the outside of left forearm”; * 03/26/25: “small nickel-sized discoloration on left side in the middle of ribs”; * 03/31/25: “discoloration found on right hip”; * 04/29/25: “medium-sized bruise on right buttocks”; * 05/09/25: “fifty cent piece-sized skin tear to right arm below elbow”; * 05/09/25: “small dime-sized dark discoloration on upper left front of thigh”; and * 05/23/25: “dime-sized discoloration on left knee”. Each of these injuries was documented as unwitnessed, and in each case Resident 6 was unsure of how the injuries occurred. There was no evidence these incidents were investigated to rule out abuse or suspected abuse. In an interview on 06/03/25 at 10:05 am, Staff 1 (ED) and Staff 2 (RCC) confirmed none of the injuries had been reported to the local SPD office. On 06/04/25 at 1:40 pm, the need to investigate each resident incident to rule out abuse or suspected abuse and report to the local SPD office as required, was discussed with Staff 1, Staff 2, Staff 3 (Health Services Director) and Staff 4 (Personal Care Assistant Supervisor). They acknowledged the findings. Staff 1 was asked to report the incidents that were not investigated to the local SPD office, and confirmation of this reporting was provided to the survey team prior to survey exit. 2. Resident 5 moved into the facility in 11/2022 with diagnoses including age related cognitive decline and osteoporosis. The resident’s service plan, dated 04/14/25, progress notes, dated 03/05/25 through 06/02/25, and incident reports, dated 02/26/25 through 05/24/25, were reviewed. The following incidents lacked a facility investigation to rule out abuse or suspected abuse, or documentation the local SPD office was contacted if abuse could not be ruled out: * 04/10/25: Fall with staff documenting the resident was "sore today" and pain in his/her "left arm" and specifically in his/her "wrist and hand"; * 04/21/25: Unwitnessed fall; * 04/26/25: Unwitnessed fall; and * 05/03/25: Fall with staff documenting, "[resident's] right shoulder blade was sticking out more than other side" and noted a "colored area on [his/her] right buttock". The resident "was not able to answer questions" and was "moaning" and complaining of "right hip, right shoulder, and right foot" pain and was sent to the emergency department. The need to ensure the facility investigated incidents to rule out abuse or suspected abuse and contact the local SPD office if abuse could not be ruled out was discussed with Staff 1 (ED), Staff 2 (RCC), Staff 3 (Health Services Director), and Staff 4 (Personal Care Assistant Supervisor) on 06/04/25. They acknowledged the findings.

• Policy and Procedure Update: The facility's Incident Reporting and Abuse Investigation policies were reviewed and revised to clarify that: o All falls or injuries of unknown origin will be treated as potential abuse until abuse can be reasonably ruled out. o If abuse cannot be ruled out, a report will be made to the local SPD within the mandated timeframe. • Staff Training: All direct care staff, med aides, charge staff, and administrators received retraining on: o Mandatory abuse reporting requirements. o Proper procedures for investigating incidents, especially those involving falls or injuries of unknown origin. o Documentation standards to clearly reflect investigative steps and conclusions. • Incident Review Protocol: A new protocol was implemented requiring: o Immediate supervisory review of all incident reports within 24 hours. o Completion of a standardized Injury of Unknown Origin Investigation Form. o Mandatory reporting to SPD if the origin remains unclear or if abuse cannot be reasonably ruled out. 3. Monitoring and Quality Assurance • Weekly Incident Review Meetings: The Administrator or RCC will lead weekly quality assurance meetings to review all incident reports and ensure proper documentation and reporting to SPD has occurred when necessary. • Monthly Audit: A random audit of 10% of all incident reports from the prior month will be conducted to ensure: o Investigations were timely. o Appropriate conclusions were documented. o SPD was notified when applicable. • Documentation Checklist: A checklist will be attached to each incident report requiring staff to confirm that investigation steps were completed and whether SPD notification was necessary. 4. Responsible Party The Administrator and Resident Care Coordinator (RCC) are jointly responsible for: • Ensuring timely investigations. • Reporting suspected abuse. • Monitoring compliance through the new QA systems.

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

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure the kitchen was clean and in good repair, staff practiced proper food-handling procedures, and staff were properly trained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: The kitchen was toured on 10/09/24 at 9:57 am. 1. The following areas needed cleaning or repair: * Dried debris on the underside of the mixer mechanism of the large mixer; * One corner of a door of an upper kitchen cabinet was damaged, exposing bare wood, which created an uncleanable surface; * There was some debris in the ridges of the serving cart push handles; * The vent on the right side of the ice machine was covered in dust debris; * The vent above the central exhaust hood in the center of the kitchen had dust debris; * There were missing tiles along the baseboard near the hand wash sink; * There was some white-colored debris on the front of the wire shelves and some debris on the cooling fan grate in the walk-in refrigerator; * A wooden storage cabinet, used to store plastic bakeware, had worn areas on the shelves, which exposed bare wood and created uncleanable surfaces; * Two commercial coffee makers were placed on a storage rack with a worn particleboard shelf with exposed wood which created an uncleanable surface; and * The grates of three portable fans used throughout the kitchen were covered in dust debris. 2. The facility utilized direct caregiving staff to deliver plates of food and beverages to residents in the dining room. During an observation of meal service on 10/09/24 from 11:45 am to approximately 12:30 pm, the caregiving staff were not observed to don any type of protective linen or single-service/single-use article to ensure their outer clothing was clean to prevent contamination of food. 3. Review of the kitchen employees’ completion of food safety training determined 3 of 12 employees (#s 10, 11 and 12) did not have a certified Oregon Food Handlers card. The need to ensure the kitchen was clean and in good repair, that caregiving staff donned some type of protective article prior to handling food plates and all kitchen employees obtained a certified Oregon Food Handlers card prior to preparing food, was discussed with Staff 1 (ED), Staff 13 (Food Services Manager) and Staff 14 (Healthcare Services Group - District Manager) on 10/10/24. They acknowledged the findings.

This rule will be met by the dietary manager has created a cleaning schedule to make sure that all areas of the kitchen are cleaned throughly. The maintenance department has made the repairs to the worn surface areas to make them a cleanable surface. The tiles along the baseboard near the hand wash sink have been repaired. The dietary staff will make sure to report any areas of concern to the Administrator or to maintenance to maintaining the kitchen in working order. Making sure that the kitchen staff has all the proper training will be followed by the Dietary Manager and HR to make sure that all trainings and certifications are current.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by:

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: Based on interview and record review, it was determined the facility failed to ensure resident move-in evaluations indicated who was involved in the evaluation process and addressed all required elements for 1 of 1 sampled resident (#3) whose new move-in evaluation was reviewed. Findings include, but are not limited to: Resident 3 moved into the facility in 07/2024. The new move-in evaluation did not indicate who was involved in the evaluation process and failed to address the following elements: * Visits to health practitioner(s), ER, hospital or NF in the past year; * Ability to use the call system; * Pain: pharmaceutical and non-pharmaceutical interventions; * Skin condition; * Nutrition habits and fluid preferences; * List of treatments: type, frequency and level of assistance needed; * Indicators of nursing needs including potential for delegated nursing tasks; * Complex medication regimen; * History of dehydration or unexplained weight loss or gain; * Elopement risk or history; * Smoking; * Alcohol and drug use; and * Environmental factors that impact the resident's behavior including lighting and room temperature. The need to ensure move-in evaluations indicated who was involved in the evaluation process and addressed all required elements was discussed with Staff 1 (ED) and Staff 2 (RCC) on 10/10/24 at 1:45 pm. The findings were acknowledged.

We are implementing a triple check system to ensure that the full evaluation process is complete. The triple check system will include, the RN, RCC, Administrator and medical records to flag if anything is missing from the move in evaluation. Resident 3 passed away on 11/1/2024 before we were able to update the record to complete their move-in evaluation. This will be audited by the Administrator and medical records a week after a new admit.

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: Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 7) whose evaluation was reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 7 moved into the facility in 03/2025 with diagnoses including hypertension and sepsis. The resident’s move in evaluation and service plan were reviewed. The following required elements were not addressed: * Customary routines including eating; * Social and leisure activities; * Vital signs if indicated by diagnoses, health problems, or medications; * Pharmaceutical and non-pharmaceutical interventions for pain; * Nutrition habits, fluid preferences, and weight if indicated; * Complex medication regimen; * History of dehydration or unexplained weight loss or gain; * Recent losses; * Unsuccessful prior placements; * Smoking, ability to smoke safely; * Alcohol and drug use - not prescribed by a physician must be evaluated and addressed; * Environmental factors that impact the resident's behavior including, but not limited to noise, lighting, room temperature; * Preferred name; * Preferred pronouns; and * Gender identity. The need to ensure the move-in evaluation included all required elements was reviewed with Staff 1 (ED) on 06/03/25. She acknowledged the findings.

• A full audit of all active resident move-in evaluations and service plans was conducted immediately following the citation. • All missing elements identified during the audit were corrected, including updates to reflect: o Customary routines (e.g., eating, sleeping, social preferences) o Pain management strategies (both pharmaceutical and non-pharmaceutical) o Nutrition habits, fluid preferences, weight history (if clinically indicated) o Complex medication regimens o History of dehydration, weight loss/gain, and prior placement challenges o Smoking and alcohol/drug use o Environmental factors affecting behavior o Personal identity elements: preferred name, pronouns, and gender identity • Affected residents and/or their representatives were contacted to assist in gathering necessary information and consenting to updates. 2. Systemic Measures to Prevent Recurrence • Forms Revision: All move-in evaluation and service plan templates were revised to include all required OAR 411-054-0034 (1–6) elements explicitly as checkboxes or narrative prompts. • Admission Process Checklist: A comprehensive Move-In Compliance Checklist was created and must be completed for all new admissions prior to resident approval. The checklist will ensure all required domains are addressed and signed off by the admitting nurse and administrator or designee. • Staff Education: All nursing, admission, medical records and care planning staff received mandatory retraining on: o Regulatory requirements of OAR 411-054-0034 (1–6) o Proper documentation of resident preferences, routines, behaviors, and identity o The importance of culturally competent, person-centered planning • Resident Interviews: Going forward, resident interviews at move-in will include a structured questionnaire to capture lifestyle habits, identity preferences, behavioral/environmental needs, and pain management approaches. 3. Monitoring and Quality Assurance • Admission Audits: All new move-in files will be reviewed by the Resident Care Coordinator (RCC) within 72 hours of completion to verify inclusion of all required elements. • Monthly QA Review: A random sample of 20% of move-in evaluations and service plans will be audited monthly by the QA committee to ensure ongoing compliance. • Continuous Training: Ongoing training on assessment and service planning will be included in quarterly staff education for nurses, med aides, and administrators. 4. Responsible Party • Resident Care Coordinator (RCC) and Medical records– Responsible for ensuring complete and accurate move-in evaluations and service plans. • Administrator – Responsible for oversight of training, process audits, and compliance reporting. • The RN – Responsible for ensuring documentation is initiated and interviews are conducted thoroughly.

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. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure the service plan was reflective of resident care needs and provided clear direction regarding the delivery of services, for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 09/2015 with diagnoses including hemiplegia and hemiparesis following a cerebrovascular accident affecting the dominant side, and osteoporosis. Observations, interviews with staff and the resident, and review of the record during the survey revealed the current service plan, dated 10/04/24, was not reflective or did not provide clear direction regarding the delivery of services in the following areas: * The resident bruised easily and should be transferred carefully using a gait belt; * The resident preferred to don shoes prior to getting out of bed in the morning and touching the floor; * The resident used a bed handle to assist with transferring in and out of bed; * The resident always wore his/her watch; and * The resident preferred warm water in a cup when rinsing his/her mouth after brushing teeth. The need to ensure the service plan included all pertinent information and preferences regarding the resident’s care needs was reviewed with Staff 1 (ED) and Staff 2 (RCC) on 10/10/24. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 12/2023 with diagnoses including history of broken back, low back pain and osteoporosis. Observations, interviews with staff and the resident, and review of the record during the survey revealed the current service plan, dated 09/19/24, was not reflective or did not provide clear direction regarding the delivery of services in the following areas: * Use of an alternating pressure air mattress and instructions for monitoring; * The resident preferred his/her apartment door to be open; and * Items to provide on the resident’s over bed table, including his/her phone and tablet (a type of laptop computer). The need to ensure the service plan included all pertinent information and preferences regarding the resident’s care needs was reviewed with Staff 1 (ED) and Staff 2 (RCC) on 10/10/24. They acknowledged the findings. 3. Resident 2 was admitted to the facility in 10/2023. Resident 2 was receiving hospice services at the time of the survey. Observations, interviews with staff and the resident, and review of the record during the survey revealed the current service plan, dated 08/06/24, was not reflective or did not provide clear direction regarding the delivery of services in the following areas: * Dressing assistance; * Vision and use of glasses; * Use of a wheel chair; * Level of assistance needed with colostomy bag and care; and * Oxygen. The need to ensure the service plan was reflective of Resident 2's current needs and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (RCC) on 10/10/24 at 1:45 pm. They acknowledged the service plan was not reflective in several areas and needed to be updated. No further information was provided. 4. Resident 3 was admitted to the facility in 07/2024. Observations, interviews with the resident and staff, and review of the service plan, last updated on 09/30/24, revealed it was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas: * Dining location preference; * Pain management; and * Skin breakdown The need to ensure service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (ED) and Staff 2 (RCC) on 10/10/24 at 1:45 pm. The staff acknowledged the findings.

The quarterly care team meetings are now more indepth of what the floor aids are actually doing for the residents. The floor staff have a report that they can do to notify the RN, RCC of any changes with the residents prior to their quarterly assessments. Allowing for us to make the proper changes when the changes first occur. The resident will be invited to attend the care team meeting and we will ask that the resident go over the service plan and sign if they agree with it. Family members will also be invited to the care team meetings, if they are not able to attend the RN will call family members and update them of any changes and let the family voice any concerns that they may have. This rule has been corrected by the services plans were updated to match the specific residents current needs. Residents 1, 2,and 4 care plans were updated. Resident 3 had passed away. This will be followed by the RN, RCC, and Administrator.

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of resident's current health status and provided clear direction to staff for 1 of 2 sampled residents (# 5) whose service plans was reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 5 moved into the facility in 11/2022 with diagnoses including age-related cognitive decline and osteoporosis. The resident’s service plan, dated 04/14/25, and ALF Care Plan Updates, dated 04/01/25 through 05/07/25, were reviewed. The resident was observed, and staff were interviewed. The service plan was not reflective of Resident 5’s current care needs or lacked caregiving instruction in the following areas: * Conflicting information on if the resident was independent with eating or if staff needed to provide assistance; * Resident 5 consistently removing the right hearing aide; * The use of glasses; * Ability to use the call light; * Frequency of staff performing safety checks; * If the resident was repeating the word, "please,” seating him/her away from other residents in common areas; * Specific instruction on how staff can redirect the resident; * Current skin condition; * Current fall interventions; and * Ensuring the table s/he ate at in his/her apartment was clean and free of food debris. The need to ensure service plans were reflective of resident needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (RCC), Staff 3 (Health Services Director), and Staff 4 (Personal Care Assistant Supervisor) on 06/04/25. They acknowledged the findings.

• An immediate audit of all current resident service plans was conducted to identify and correct deficiencies where health changes were not accurately reflected. • Service plans that were incomplete or unclear were revised in collaboration with licensed nursing staff, care team members, and the resident or their representative. • All affected staff were informed of updated service plans and received verbal and written communication to ensure they understood the revised care directions. 2. Systemic Changes to Prevent Recurrence • Service Plan Review Policy Updated: Policies were revised to mandate that: o Service plans must be reviewed and updated within 48 hours of a significant change in condition, following quarterly assessments, or after any hospitalization or health event. o Plans must include specific, measurable, and clear instructions to direct care staff in delivering individualized support. • Standardized Documentation Templates: A new service plan template was adopted to include: o A health summary reflective of the resident’s current physical, emotional, and cognitive condition. o Specific care directives for each ADL and IADL domain. o Instructions regarding medication support, behavioral concerns, mobility, nutritional needs, and safety precautions. o Clear delegation of tasks for unlicensed staff, including frequency, techniques, and special considerations. • Staff Retraining: All nurses, med aides, and caregiving staff received retraining on: o The purpose and structure of a legally compliant and clinically appropriate service plan. o The importance of timely updates and how to report health changes for prompt documentation. o How to access, interpret, and follow service plans as part of routine care delivery. • Care Conferences Reinforced: Interdisciplinary care conferences with the resident or representative are now scheduled: o Upon move-in o Every 90 days o Upon any change of condition o With outcomes documented directly into the service plan 3. Monitoring and Quality Assurance • Monthly Audits: The Resident Care Coordinator (RCM) and PSA Supervisor will conduct monthly audits of 20% of service plans to ensure: o They reflect current health status o They include specific, actionable directives o They are signed by required parties • Weekly Change of Condition Reports: A log of all incident reports, med changes, and condition changes will be reviewed weekly by the nursing and administrative team to flag any needed service plan updates. • Staff Communication Huddles: Brief shift-change huddles are now held to reinforce any service plan changes that occurred in the previous 24–48 hours. 4. Responsible Party • Resident Care Coordinator (RCC) – Oversees updates, care conferences, and plan quality. • Administrator – Ensures systems for monitoring, staff compliance, and policy adherence. • The RN – Ensures clinical accuracy of the plans and provides frontline education to caregivers.

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 411-054-0036 (5) Service Plan: Service Planning Team (5) SERVICE PLANNING TEAM. The service plan must be developed by a Service Planning Team that consists of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident. Involved family members and case managers must be notified in advance of the service-planning meeting.(a) As applicable, the Service Planning Team must also include:(A) Local APD or AAA case managers and family invited by the resident, as available.(B) A licensed nurse if the resident shall need, or is receiving nursing services or experiences a significant change of condition as required in 411-054-0045(1)(f)(D) (Resident Health Services).(C) The resident's physician or other health practitioner.(b) Each resident must actively participate in the development of the service plan to the extent of the resident's ability and willingness to do so. If resident participation is not possible, documentation must reflect the facility's attempts to determine the resident's preferences. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the resident’s service plan was developed by a Service Planning Team which consisted of the resident, the resident’s legal representative, if applicable, and any person of the resident’s choice, for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to: a. During a group interview with seven residents (which included Resident 2) on 10/09/24, all residents stated they had not seen their service plans and had not been a part of their service plan reviews. b. Resident 1, 2, 3 and 4’s current service plans lacked documented evidence the resident had reviewed the service plan. In an interview on 10/09/24, Staff 1 (ED) and Staff 2 (RCC) explained that the facility’s process for reviewing and updating a resident’s service plan was to conduct multiple evaluations – one by the nurse, one by the Life Enrichment Coordinator and one by the RCC – to capture current information regarding the resident’s health, activity interests and overall satisfaction with the facility. Staff 1 and 2 felt the resident’s input during the evaluations met the rule requirement for including the resident in the development of his/her service plan. However, they acknowledged the facility did not specifically review changes made to the service plan as a result of the evaluations with the resident to obtain their consent. The need to ensure the resident, the resident’s legal representative, if applicable, and any person of the resident’s choice was included in the development and review of his/her service plan was reviewed with Staff 1 and Staff 2 on 10/10/24. They acknowledged they needed to revise their service plan review process to involve the resident, the resident’s legal representative and any person of the resident’s choice.

The updated policy will be that the resident and the family will be invited to the care plan meeting. If they do not want to attend the RN or the RCC will go over the service plan with the resident and the family member. This rule was corrected by the care plans were reviewed with Residents 1, 2 and 4. Resident 3 has passed away. The RN, RCC, and the Administrator will ensure that this rule is followed. This will be auditted monthly to ensure compliance.

OAR 411-054-0036 (5) Service Plan: Service Planning Team (5) SERVICE PLANNING TEAM. The service plan must be developed by a Service Planning Team that consists of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident. Involved family members and case managers must be notified in advance of the service-planning meeting.(a) As applicable, the Service Planning Team must also include:(A) Local APD or AAA case managers and family invited by the resident, as available.(B) A licensed nurse if the resident shall need, or is receiving nursing services or experiences a significant change of condition as required in 411-054-0045(1)(f)(D) (Resident Health Services).(C) The resident's physician or other health practitioner.(b) Each resident must actively participate in the development of the service plan to the extent of the resident's ability and willingness to do so. If resident participation is not possible, documentation must reflect the facility's attempts to determine the resident's preferences. 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, document and communicate to staff what action or intervention was needed for a resident following a short term change of condition, and monitor each resident consistent with his or her evaluated needs and service plan, for 3 of 4 sampled residents (#s 1, 3 and 4) who experienced changes of condition requiring monitoring. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 09/2015 with diagnoses including hemiplegia and hemiparesis following a cerebrovascular accident affecting the dominant side, and osteoporosis. Resident 1’s records, including the current service plan, dated 10/04/24, service plan updates, progress notes from 07/08/24 through 10/08/24 were reviewed, observations were made, and interviews were conducted. The facility documented the following changes of condition for Resident 1: * 07/14/24: Buttock swollen and irritated; * 07/17/24: Dark purple discoloration on right bicep; * 07/25/24: Rash on belly; * 08/18/24: Choked on medication/pills; * 08/20/24: Discoloration right ankle; * 08/25/24: Choked on medication/pills; * 08/27/24: Discoloration on left hand; * 09/07/24: Three sores on right thigh; * 09/27/24: Discoloration on right arm; and * 09/30/24: Red and purple discoloration on left hand. For each of these short-term changes of condition, there was no documented evidence the facility determined, documented and communicated to staff what actions or interventions were needed for the resident. The need to ensure the facility had a process to determine and document what actions or interventions were needed for a resident following a change of condition and communicate those instructions to staff, was reviewed with Staff 1 (ED) and Staff 2 (RCC) on 10/10/24. They acknowledged the findings. No additional documents were provided. 2. Resident 4 was admitted to the facility in 12/2023 with diagnoses including history of broken back, low back pain and osteoporosis. Resident 4’s records, including the current service plan, dated 09/19/24, service plan updates, progress notes from 07/08/24 through 10/08/24 were reviewed, observations were made, and interviews were conducted. The facility documented the following changes of condition for Resident 4: * 07/25/24: Red/purple discoloration on top of left wrist; * 08/05/24: Discoloration left shoulder; * 08/21/24: Redness on top of coccyx; * 09/03/24: Scratches on right shoulder; * 09/08/24: Lip and gums red and swollen; and * 10/07/24: Discoloration on left forearm. For each of these short-term changes of condition, there was no documented evidence the facility determined, documented and communicated to staff what actions or interventions were needed for the resident. The need to ensure the facility had a process to determine and document what actions or interventions were needed for a resident following a change of condition and communicate those instructions to staff, was reviewed with Staff 1 (ED) and Staff 2 (RCC) on 10/10/24. They acknowledged the findings. No additional documents were provided. 3. Resident 3 was admitted to the facility in 07/26/24. Resident 3’s record including incident investigations, the current service plan last updated 09/30/24 and progress notes from 07/26/24 through 10/08/24 were reviewed, observations were made, and interviews with the resident and staff were conducted. Resident 3's clinical record and charting notes revealed the following: * Resident 3 fell four times between 07/31/24 and 09/20/24. * The facility failed to investigate the circumstances for two of the four falls (08/19/24 and 09/20/24) to determine if service-planned interventions were evaluated, monitored for effectiveness, or if new interventions were needed. The need to ensure the facility evaluated and monitored fall interventions to determine if they were effective or if new interventions were needed was shared with Staff 1 (ED) and Staff 2 (RCC) on 10/10/24 at 1:45 pm. They acknowledged the findings. No new information was provided.

The policy for change of condition has been updated, when the RN does a change of condition she will let the RCC know and a note will be made for the staff in staff communications relaying what the staff needs to be doing for the resident to care for them with the change of condition. The resident service plan will be updated with the change of condition and with the directions for the staff to properly take care of the resident. The new process in place for reviewing falls to ensure that staff are following service plans and to make sure that the service plan is appropriate for the resident is, make sure all interventions were being used to prevent a fall, if they were not, find out why they were not. If all intervention were being used and we still had a fall, the care team will meet and talk with the provider to see what other interventions we can implement to help prevent falls. This will be followed by the RN, RCC and Administrator to make sure this rule is being followed.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the resident was evaluated each time a change of condition occurred, actions or interventions were determined and documented, the actions or interventions were communicated to staff on each shift, and the condition was monitored with weekly progress noted until resolution for 1 of 2 sampled residents (# 5) who were reviewed for changes of condition. This is a repeat citation. Findings include, but are not limited to: Resident 5 moved into the facility in 11/2022 with diagnoses including hypertension, age-related cognitive decline, and osteoporosis. The resident's service plan, dated 04/14/25, ALF Care Plan Updates, dated 04/01/25 through 05/07/25, progress notes, dated 03/05/25 through 06/02/25, and MARs, dated 05/01/25 through 06/02/25, were reviewed. Resident 5 was observed, and staff were interviewed. The following changes of condition lacked documentation of determined actions or interventions, communication of the actions or interventions to staff on each shift, and/or monitoring through resolution: * 04/08/25: Staff documenting that the resident was "acting strange" with increased weakness and being tired; * 04/10/25: Fall; * 04/26/25: Fall; * 05/03/25: Fall; * 05/05/25: Elevated blood pressure; * 05/13/25: Resident 5 was not administered his/or noon dose of irbesartan (for hypertension) as s/he "was sleeping." Later staff documented the resident having an elevated blood pressure; * 05/14/25: Elevated blood pressure; * 05/19/25: Fluctuating high and low blood pressures during the day; and * 05/24/25: Fall with left hand fracture. In addition, there was documentation that the facility did not administer one or more of the following medications 27 times due to Resident 5 sleeping, being out of the facility, or refusing the medication: * Alprazolam (for anxiety); * Cetirizine (for itching); * Citalopram (for age related anxiety); * Irbesartan; * Meloxicam (for pain); * Macrobid (antibiotic to treat an infection); * Seroquel (for age related cognitive decline); and * Ibuprofen (for pain). There was no documented evidence the resident was monitored for not receiving the above medications. The need to ensure the facility determined and documented actions or interventions for resident’s changes of condition, communicated the actions or interventions to staff on each shift, and monitored the condition through resolution was discussed with Staff 1 (ED), Staff 2 (RCC), Staff 3 (Health Services Director), and Staff 4 (Personal Care Assistant Supervisor) on 06/03/25. They acknowledged the findings.

• The resident(s) involved in the citation were immediately reassessed by the RN • Any missing documentation regarding interventions and shift-to-shift communication was completed retrospectively to the best extent possible. • Affected direct care staff and licensed personnel were immediately updated on the status of the resident(s) and re-educated on proper documentation and communication procedures. 2. Systemic Changes to Prevent Recurrence a. Policy and Procedure Update • The Change of Condition Policy was revised to ensure the following: o The RN will evaluates changes of condition within 24-48 hours of identification or report. o Documented interventions or clinical actions are clearly recorded in the progress notes and on a designated “Change of Condition” form. o Shift-to-shift communication of changes is required through: ? Verbal report at shift change ? Documentation in the 24-hour communication log ? Notation in electronic health record (EHR), if applicable b. Standardized Documentation Tools • A standardized Change of Condition Monitoring Tool was implemented, including: o Initial assessment findings o Actions/interventions taken o Daily monitoring and weekly progress notes o Resolution date and outcome c. Staff Education and Training • All nursing staff, med aides, and caregivers received in-service training on: o Identification and timely reporting of changes in resident condition o Documentation of assessments and interventions o Importance of clear communication across shifts o Guidelines for when to escalate to licensed personnel or physician d. Team Communication Protocol • Daily clinical stand-up meetings were implemented to: o Review recent changes of condition o Ensure communication has occurred on all shifts o Assign responsibility for follow-up and progress notes 3. Monitoring and Quality Assurance • Weekly Review: The Resident Care Manager (RCM) or PSA supervisor will review all documented changes of condition weekly to ensure: o Timely assessments and documentation o Proper follow-up and progress notes until resolution o Interventions are individualized and appropriate • Monthly Chart Audits: The Care Team, RCC, RN, PSA supervisor and Administrator will conduct monthly audits on a sample of 10% of resident charts to ensure compliance with change-of-condition protocols. • Ongoing Education: Change-of-condition documentation and communication will be a standing topic in quarterly staff training and monthly QA meetings. 4. Responsible Party • Resident Care Coordinator (RCC) – Oversees clinical response and documentation for changes of condition. • Administrator – Responsible for ensuring systemic compliance and staff accountability. • The RN – Ensure communication of resident changes during shift report and daily documentation is completed.

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

OAR 411-054-0055 (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 for 1 of 2 sampled residents (# 5) whose MARs and physician's orders were reviewed. Findings include, but are not limited to: Resident 5 moved into the facility in 11/2022 with diagnoses including hypertension and age-related cognitive decline. The resident's 05/01/25 through 06/02/25 MARs and prescriber orders were reviewed. The resident was not administered one or more of the following medications due to him/her "sleeping" on 25 occasions: * Alprazolam (for anxiety); * Cetirizine (for itching); * Citalopram (for age related anxiety); * Irbesartan (for hypertension); * Meloxicam (for pain); * Seroquel (for age related cognitive decline); and * Ibuprofen (for pain). The need to ensure medication orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 2 (RCC), Staff 3 (Health Services Director), and Staff 4 (Personal Care Assistant Supervisor) on 06/04/25. They acknowledged the findings.

• Upon discovery of the deficiency, an immediate audit of all current resident medication administration records (MARs) was conducted to identify any discrepancies or missed medication orders. • Any missed or incorrectly administered medications were reviewed with the prescribing provider for guidance on corrective measures. • Affected residents and their representatives were notified as appropriate. • Involved staff were counseled, retrained, and corrective action was taken where necessary. 2. Systemic Changes to Prevent Recurrence a. Policy Review and Revision • The Medication Administration Policy was revised to reinforce: o All medications must be administered exactly as ordered by the prescribing provider. o Any clarification needed on medication orders must be obtained prior to administration or omission. o All MAR documentation must reflect accurate timing, dosage, and route. b. Standard Operating Procedures Implemented • A new Double-Check System was instituted at the beginning of each shift: o Incoming staff review the MAR for the past 24 hours for accuracy and completeness. o Any discrepancies must be reported to the nurse immediately and resolved before the next medication pass. • Medication Change Tracker Log was created to record: o All new orders o Discontinuations o Dosage/frequency changes o Implementation confirmation c. Staff Training • All med aides and licensed staff received immediate retraining on: o Safe medication administration practices o Reading and interpreting provider orders o Documentation standards o When and how to question or clarify orders • Training included a skills validation component, ensuring that staff demonstrate competency in carrying out orders precisely. 3. Monitoring and Quality Assurance • Daily MAR Reviews: Charge nurses or med supervisors review MARs daily to check for: o Missed doses o Incorrect documentation o Medication errors • Weekly Audit: The Resident Care Coordinator (RCC) or PSA Supervisor conducts weekly audits of a sample of 10% of resident MARs to ensure ongoing compliance. • Error Reporting Log: All medication errors or deviations from orders are documented in a Medication Error Log and reviewed monthly during QA committee meetings to identify trends and opportunities for improvement. 4. Responsible Party • Resident Care Coordinator (RCC) – Responsible for monitoring medication practices and ensuring policy adherence. • Administrator – Oversees the implementation of the corrective plan and holds staff accountable for compliance. • The RN, PSA Supervisor and Med Aides – Responsible for safe medication administration and immediate reporting of any discrepancies.

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 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the physician or other practitioner was notified if a resident refused consent to an order, for 1 of 1 sampled resident (#4) with documented refusals of a prescribed treatment. Findings include, but are not limited to: Resident 4 was admitted to the facility in 12/2023 with diagnoses including history of broken back, low back pain and osteoporosis. Resident 4 was prescribed lidocaine external patch (for pain) – apply two patches to lower back one time per day for 12 hours. Review of the 09/01/24 through 10/08/24 MAR and TAR indicated Resident 4 refused the treatment on 09/03/24 and then daily from 09/06/24 through 10/08/24. There was no documented evidence the facility notified the physician or other practitioner of the refusals. In an interview on 10/10/24, Staff 4 (Lead MT) confirmed the facility did not have a process for immediately notifying a prescriber when a resident refused consent to an order. The need to ensure the physician or other practitioner was notified if a resident refused consent to an order was reviewed with Staff 1 (ED) and Staff 2 (RCC) on 10/10/24. They acknowledged the findings.

The updated policy for this rule is the med tech will notify the RN if a resident has refused their medication or any treatments. The RN will notify the residents provider to let them know that the resident has refused medication or treatment. The RN will ask the provider what they want us to do and how often they want to be notified when the resident refuses medication or treatment. A note will be made in the residents chart and what the provider wants us to do when the resident refuses. This rule was corrected by Resident 4's primary care provider was notified of the refusals of the lidocaine patch. The provider has given us further instructions for refusals. Every week the RN will review the MAR for any refusals and follow up with the provider. The RN will also check with the med tech to make sure that all refusals are being reported and documented. This will be followed by the RN, RCC, and the Administrator to ensure it is being done.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 2 of 2 sampled residents (#s 5 and 6) who had documented medication refusals. This is a repeat citation. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 05/2023 with diagnoses including hypertension, arthritis, and cognitive impairment. Review of Resident 6's MAR, dated 05/01/25 through 06/02/25, identified the following documented refusals: * Magnesium oral tablet 400 mg (nutritional supplement): six occasions; and * Algae-based calcium tablet (nutritional supplement): 14 occasions. In an interview on 06/04/25 at 10:05, Staff 3 (Health Services Director) confirmed Resident 6’s physician was not notified of the medication refusals. On 06/04/25 at 1:40 pm, the need to ensure the facility notified physicians/practitioners each time a resident refused to consent to orders was discussed with Staff 1 (ED), Staff 2 (RCC), Staff 3, and Staff 4 (Personal Care Assistant Supervisor). They acknowledged the findings. 2. Resident 5 moved into the facility in 11/2022 with diagnoses including hypertension, age-related cognitive decline, and osteoporosis. The resident’s MARs, dated 05/01/25 through 06/02/25, signed prescriber orders, dated 02/05/25, and progress notes, dated 03/05/25 through 06/02/25, were reviewed. There was no documented evidence the facility notified the prescriber of the following refusals: * Citalopram (for age related anxiety): One occasion; * Ketoconazole (for itching): Five occasions; and * Meloxicam (for pain): One occasion. The need to ensure the prescriber was notified each time a resident refused to consent to orders was discussed with Staff 1 (ED), Staff 2 (RCC), Staff 3 (Health Services Director), and Staff 4 (Personal Care Assistant Supervisor) on 06/04/25. They acknowledged the findings.

• The specific incident involving a resident’s refusal of orders was immediately reviewed. • The resident’s physician was contacted and notified of the refusal. • Documentation was updated in the resident’s chart to reflect the refusal, physician notification, and any follow-up orders or instructions received. • The involved staff received immediate feedback and retraining on refusal procedures and notification requirements. 2. Systemic Changes to Prevent Recurrence a. Policy Revision and Clarification • The facility’s Medication and Treatment Refusal Policy was reviewed and revised to clearly require that: o Any refusal of prescribed treatment or medication must be documented in the resident’s record. o The prescribing practitioner must be notified within 24 hours, or sooner if clinically indicated. o Documentation must include the date/time of the refusal, staff response, notification to the provider, and any new instructions. b. Standardized Documentation • A Refusal of Treatment Notification Form was developed and implemented to ensure that: o All resident refusals are logged and followed up with provider contact. o Communication to the practitioner is documented clearly, including method (fax, call, EHR). o Follow-up care instructions or changes to orders are recorded in the resident’s service plan and communicated to care staff. c. Staff Training and Education • All licensed nurses, med aides, and care staff were retrained on: o The importance of documenting and reporting treatment refusals. o The legal and clinical obligation to inform the physician/practitioner. o How to appropriately counsel residents on the consequences of refusing care while respecting their rights. 3. Monitoring and Quality Assurance • Weekly Review: The Resident Care Coordinator (RCC) or designee will review all refusal documentation weekly to ensure: o Physician notification occurred o Follow-up care was implemented o Staff actions were in accordance with policy • Monthly QA Audits: The QA Committee will conduct monthly audits of 10% of resident charts to ensure proper handling of medication/treatment refusals and provider notifications. • Incident Reporting Integration: All treatment or medication refusals will now be entered into the facility’s incident tracking system for visibility and accountability. 4. Responsible Party • Resident Care Coordinator (RCC) – Ensures physician notification procedures are followed and documented. • The RN – Responsible for notifying the provider immediately upon refusal and recording it properly. • Administrator – Oversees compliance monitoring, staff training, and policy enforcement.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by:

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included specific instructions for PRN (as needed) medications for 3 of 4 sampled residents (#s 1, 3, and 4) whose medications were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 07/2024 with diagnoses including constipation. Resident 3 had physician orders for the following PRN bowel medications: docusate sodium one capsule every 12 hours as needed, and magnesium hydroxide suspension 30 ml once a day as needed. Residents 3's MARs were reviewed from 09/01/24 through 10/08/24 and the following was noted: * Lack of resident-specific instructions for multiple PRN bowel medications, including sequence of administration. In an interview on 10/10/24 at 11:00 am, Staff 2 (RCC) reviewed the resident's MAR. She confirmed the multiple PRN bowel medications lacked specific instructions for staff. The need for the facility to ensure MARs were accurate and provided clear instruction to unlicensed staff was discussed Staff 1 (ED) and Staff 2 (RCC) on 10/10/24 at 1:45 pm. The findings were acknowledged. No further information was provided. 2. Resident 1 was admitted to the facility in 09/2015 with diagnoses including hemiplegia and hemiparesis following a cerebrovascular accident affecting the dominant side, and osteoporosis. Review of the 09/01/24 through 10/08/24 MAR indicated the resident was prescribed the following PRN medications: * Hydrocortisone topical gel and nystatin topical cream – both as needed “for itching;” and * Ibuprofen “for pain” and acetaminophen extra strength for “mild pain.” The facility failed to ensure there were resident-specific parameters and instructions for unlicensed staff as to which medication to administer and for what condition. The MAR was reviewed with Staff 1 (ED) and Staff 2 (RCC) on 10/10/24. They acknowledged the lack of resident-specific parameters and instructions for the PRN medications. 3. Resident 4 was admitted to the facility in 12/2023 with diagnoses including history of broken back, low back pain and osteoporosis. Review of the 09/01/24 through 10/08/24 MAR indicated the resident was prescribed Imodium A-D 2 mg tablets as needed for diarrhea. The instructions provided by the prescriber were as follows: * “Give 1 tablet by mouth every 4 hours as needed for diarrhea give 1 tablet after each subsequent loose stool”; and * “Give 2 tablets by mouth every 4 hours as needed for diarrhea give 2 tablets after first loose stool, give 1 tablet after each subsequent loose stool.” The instructions were not written in a way that was clear for unlicensed staff as to whether they were to administer 1 tablet, or 2 tablets as evidenced by 2 of 5 instances where the facility administered 1 tablet after Resident 4’s first loose stool. The MAR was reviewed with Staff 1 (ED) and Staff 2 (RCC) on 10/10/24. They acknowledged the lack of clear resident-specific parameters and instructions for the PRN medication.

The updated policy is that the RN, RCC, and Administrator will look through the MAR and the orders weekly to make sure that the MAR and the orders match. If they do not, the RN will reach out to the provider to get clarification and parameters for the medication tell the med aide what medication to use and what order the medication needs to be given in if there are more than one order. This rule has been corrected by we received clarification for the residents and corrected their orders and MAR. This will be followed by the RN and RCC to ensure this being done correctly.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure MARs were included specific instructions for PRN medications for 1 of 2 sampled residents (# 5) whose medications were reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 5 moved into the facility in 11/2022 with diagnoses including constipation and age-related cognitive decline. The following PRN medications used to treat constipation did not have resident-specific parameters to direct unlicensed staff on the sequential order of administration: * Bisacodyl suppository; * Colace; * MiraLax; * Senna; and * Simethicone. In an interview on 06/04/25 at approximately 9:45 am, Staff 4 (Personal Care Assistant Supervisor) reviewed the resident's MAR and confirmed the five PRN bowel medications lacked specific instructions for staff. The need for the facility to ensure MARs were accurate and provided clear instruction to unlicensed staff was discussed Staff 1 (ED), Staff 2 (RCC), Staff 3 (Health Services Director) and Staff 4 on 06/04/25. They acknowledged the findings.

• An immediate audit of all residents’ MARs was completed to identify any PRN medications lacking: o Indications for use (e.g., pain, anxiety, constipation) o Dosage/frequency instructions o Administration parameters or hold criteria • All incomplete MAR entries were corrected by the licensed nurse or delegating nurse in collaboration with the pharmacy and prescribing providers. • Med aides and nursing staff were verbally notified of the corrections and instructed not to administer any PRN medications with incomplete MAR instructions. 2. Systemic Changes to Prevent Recurrence a. Policy Revision • The Medication Documentation Policy was revised to require that all PRN medications: o Include a clearly stated reason for administration o Include specific dosing intervals and maximum frequency per 24 hours o Include objective parameters when applicable (e.g., “Give for pain rated 6/10 or higher”) b. MAR Review Procedure • A standard MAR audit tool was developed to be used: o Upon resident admission or readmission o After any new PRN medication is prescribed o Monthly, as part of regular QA checks • Any PRN order received will now require pharmacy verification and be reviewed by the delegating nurse before being entered into the MAR system. c. Staff Training • All med aides and licensed nurses received retraining on: o How to interpret and administer PRN medications only when complete instructions are present o How to recognize incomplete PRN orders and report them immediately o How to document the reason for administration and resident response on the MAR and in progress notes 3. Monitoring and Quality Assurance • Weekly MAR Audit: The Resident Care Coordinator (RCC) or designee will audit 10% of active MARs weekly to confirm PRN medication orders contain: o Complete directions o Clear indications o Proper documentation of administration and outcomes • Monthly QA Reporting: All PRN documentation audits and any identified trends in PRN medication errors or omissions will be reported to the Quality Assurance Committee for review and follow-up action. 4. Responsible Party • Resident Care Coordinator (RCC) – Responsible for oversight of medication documentation accuracy. • The RN, RCC, PSA supervisor and Administrator – Responsible for verifying all PRN medication orders and MAR entries for completeness. • Administrator – Ensures systemic compliance and staff accountability through policy enforcement and audit review.

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

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications used to treat a resident's behavior had resident-specific parameters, staff documented that non-pharmacological interventions had been tried with ineffective results prior to administering the medications, and all direct care staff had knowledge of non-pharmacological interventions for 2 of 2 sampled residents (#s 2 and 4) who were prescribed PRN psychotropic medications. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 10/2023 and had diagnoses which included anxiety disorder. Review of the resident's service plan, physician orders, and 09/01/24 through 010/08/24 MARs revealed the following: Resident 2 was prescribed lorazepam 0.5 mg (anti-anxiety medication) one tablet every eight hours PRN for anxiety. The facility failed to ensure the resident's MAR and clinical record included the following required information: * Resident-specific parameters regarding how Resident 2 expressed anxiety; and * Non-pharmacological interventions to be attempted prior to administration of the medication. Additionally, the record lacked documentation that all direct care staff had been informed of non-pharmacological interventions for Resident 2. In an interview on 10/10/24 at 11:15 am, Staff 2 (RCC) reviewed the resident’s clinical record and acknowledged the lack of resident-specific parameters, non-pharmacological interventions. The need to ensure the required information for PRN psychotropic medications was documented in the MAR and/or clinical record was discussed with Staff 1 (ED) and Staff 2 (RCC) on 10/10/24 at 1:45 pm. They acknowledged the findings. No further information was provided. 2. Resident 4 was admitted to the facility in 12/2023 with diagnoses including history of broken back, low back pain and osteoporosis. The resident was prescribed olanzapine (an antipsychotic medication) 2.5 mg tablet – give 1 tablet by mouth every 12 hours as needed for anxiety. Review of the 09/01/24 through 10/08/24 MAR indicated: * The MAR lacked written, resident-specific parameters for how the resident expressed or exhibited anxiety; * There were no non-pharmacological interventions included in the resident’s record; and * The resident was administered the medication four times without documentation that non-pharmacological interventions had been tried with ineffective results. The need to ensure psychotropic medications that were administered PRN had written, resident-specific parameters and the medication was administered only after documented non-pharmacological interventions had been tried with ineffective results was reviewed with Staff 1 (ED) and Staff 2 (RCC) on 10/10/24. They acknowledged the findings.

The updated policy for Psychotropic medications is that the physician will write parameters for the specific resident on how that resident displays anxiety. Telling the staff what they need to watch for in that specific resident then a resident specific non-pharmacological intervention will be made for that resident to try before administering any psychotropic medications. This will be in the residents MAR and in the service plan. The MAR and the service plans have been updated to reflect the specific non-pharmacological interventions for each resident. The med tech will need to document that the non-pharmacological interventions that they tried and that they did not work before administering the psychotropic medication. The care plan was updated for Resident 2. This rule will be followed by the RN and the RCC.

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by:

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to complete or update and review the acuity-based staffing tool (ABST) evaluation for each resident no less than quarterly or whenever there was a significant change of condition for 3 of 4 sampled residents (#s 2, 3 and 4) and multiple unsampled residents, and use the results to develop and routinely update the facility’s posted staffing plan. Findings include, but are not limited to: The facility used the Department-developed acuity-based staffing tool (ABST) to document the amount of time required to complete each resident’s daily care needs. Review of the ABST on 10/08/24 indicated: 1a. The facility had not reviewed or updated Resident 2’s ABST evaluation at least quarterly and following significant changes of condition on 09/23/24 and 10/04/24. b. The facility had not created Resident 3’s ABST upon admission and reviewed or updated the evaluation following a significant change of condition on 09/19/24. c. The facility had not reviewed or updated Resident 4’s ABST evaluation since 01/03/24. d. Ten unsampled residents’ ABST evaluations had also not been reviewed and updated at least quarterly as required. 2. The facility’s posted staffing was as follows: * Day shift: 3 caregivers plus 1 medication technician; * Evening shift: 3 caregivers plus 1 medication technician; and * Overnight shift: 1 caregiver plus 1 medication technician. Though the facility was scheduling more staff on each shift than required per the ABST, when interviewed on 10/10/24, Staff 1 (ED) and Staff 2 (RCC) acknowledged they did not fully understand how to use the ABST data to develop a staffing plan. The need to ensure the facility updated and reviewed the acuity-based staffing tool (ABST) evaluation for each resident no less than quarterly or whenever there was a significant change of condition and used the results to develop and routinely update the facility’s posted staffing plan was reviewed with Staff 1 and Staff 2 on 10/10/24. They acknowledged the findings.

The updated policy for the ABST is that when the RN does a 30 day assessment or the quarterly assessment, the administrator will update the ABST to reflect the care that the resident is receiving. This will also be updated with any long term change of conditions. The rule has been corrected by, we did an audit of all the residents and have updated the ABST for all residents. We will use this summary to update our staffing to meet the ABST rule. I will continue to do trainings on ABST to make sure that we stay in compliance with this rule. This will be followed by the Administrator to ensure that this rule is being followed.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to complete or update and review the acuity-based staffing tool (ABST) evaluation for each resident prior to move-in and whenever there was a significant change of condition for 2 of 3 sampled residents (#s 5 and 7). This is a repeat citation. Findings include, but are not limited to: The facility used the Department-developed ABST to document the amount of time required to complete each resident’s daily care needs. Review of the ABST during the survey revealed: 1. The facility had not reviewed or updated Resident 5’s ABST evaluation following a significant change of condition on 05/24/25. 2. The facility had not created Resident 7’s ABST before s/he moved into the facility. The need to ensure the facility updated and reviewed the acuity-based staffing tool (ABST) evaluation for each resident before move-in and whenever there was a significant change of condition was discussed with Staff 1 (ED), Staff 2 (RCC), Staff 3 (Health Services Director), and Staff 4 (Personal Care Assistant Supervisor) on 06/05/25. They acknowledged the findings.

• An immediate audit of all current residents’ acuity-based staffing tool evaluations was conducted. • For any resident lacking a completed or updated acuity tool: o The evaluation was completed or revised by the Administrator in collaboration with the interdisciplinary team. o The updated tool was reviewed during a care team meeting and used to reassess staffing assignments and ratios. • Residents who recently experienced a change of condition were promptly reevaluated, and their care plans and staffing needs were adjusted accordingly. 2. Systemic Changes to Prevent Recurrence a. Policy and Procedure Update • The facility's Acuity-Based Staffing Tool Policy was updated to ensure: o The tool is completed prior to each resident’s move-in based on the pre-admission assessment. o The tool is reviewed and updated immediately following a significant change in condition, hospitalization, or readmission. o Evaluations are reviewed at least quarterly or more frequently if indicated by resident status. b. Admission and Change of Condition Protocols • A revised admission checklist now includes mandatory completion of the acuity-based staffing tool before move-in approval. • A change of condition protocol was implemented requiring: o Reassessment of the resident’s acuity level within 24-48 hours of a reported change. o Immediate communication of results to the Administrator to determine if staffing adjustments are required. c. Staff Education • All leadership staff, including the Administrator, RCC, the RN, and PSA supervisior, were retrained on: o When and how to complete the acuity tool o The importance of aligning staffing with assessed resident needs o Documentation procedures and where the completed tool is stored for access and review 3. Monitoring and Quality Assurance • Weekly Review: The Resident Care Manager (RCM) or designee will review all new admissions and recent incident reports weekly to verify: o Acuity tools were completed prior to move-in o Tools were updated following any significant changes • Monthly Audit: The Quality Assurance (QA) Committee will audit a random sample of 10% of resident records monthly to ensure timely and accurate use of the acuity-based staffing tool. • Quarterly Staffing Review Meetings: Staffing assignments and patterns will be reviewed quarterly using the compiled acuity data to ensure adequate coverage and care consistency. 4. Responsible Party • Resident Care Coordinator (RCC) and Administrator – Ensures the acuity tool is completed accurately and on time. • Administrator – Oversees staffing alignment with acuity needs and enforces compliance through monitoring systems. • Administrator and RCC – Ensures completion of the tool prior to move-in as part of the admission checklist process.

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

OAR 411-054-0070 (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: Based on interview and record review, it was determined the facility failed to ensure 2 of 3 caregiving staff (#s 8 and 9) demonstrated satisfactory performance in all required areas within 30 days of hire. Findings include, but are not limited to: Training records were reviewed on 10/09/24. There was no documented evidence Staff 8 (CG) and Staff 9 (CG), hired 06/07/24 and 07/18/24, respectively, had demonstrated competency in all required areas and within 30 days of hire including: * Providing assistance with ADL's. The need to ensure staff had demonstrated competence in all job duties within 30 days of hire was reviewed with Staff 2 (RCC) on 10/09/24 at 11:30 am, and Staff 1 (ED) and Staff 2 on 10/10/24 at 1:45 pm. They acknowledged the findings.

This rule will be met by the RCC and the HR will audit new hires at the 30 day to ensure that all training records are satisfactory.The staff who did not have their competency training signed off have now had the competencies signed off on. The RCC and HR will make sure this rule is followed.

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 ensure fire and life safety instruction was provided to staff on alternate months of fire drills. Findings include, but are not limited to: Fire and life safety records for 04/2024 through 09/2024 were reviewed and lacked the following components: * There was no documented evidence fire and life safety training was consistently provided to staff on alternating months of fire drills. The need to ensure the facility provided fire and life safety instruction to staff on alternate months of fire drills was discussed with Staff 1 (ED) on 10/09/24 at 1:30 pm. She acknowledged the findings.

The new policy fire and life safety are, the staff will have an inservice on the months that we do not have a fire drill. The maintance department and the Administrator will be responsible for ensuring this is done.

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

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents were re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire, and a written record of fire safety training including content of the training sessions and the residents attending, was kept. Findings include, but are not limited to: Fire safety training records for residents was reviewed on 10/09/24 with Staff 1 (ED). She explained that the facility provided fire safety training to residents at admission, but acknowledged the facility did not have a process for re-instructing the residents at least annually and documenting the content of the instruction. The need to develop a process for re-instructing residents at least annually on fire safety procedures and documenting the content of the training was reviewed with Staff 1 and Staff 2 (RCC) on 10/10/24 at 1:45 pm. They acknowledged the findings.

This rule will be met by once a year the facility will have a fire drill that the residents will actively participate in. This will be documented in the residents chart that they participated in the training. This will include a question and answer time for if the resident has any questions or concerns we can address it with them.The residents who did not have signed copy of the fire and life training have been retrained and they have signed off on the training acknowledging they have received the training. The maintainence department will do a brief training with the residents to go over the general safety procedure to what the residents need to do in case of a fire or evacuation. The activities department will also go over trainings and review with the residents at resident council meeting to help address any questions or concerns the residents may have. We will go over the designated meeting places outside of the building. We will document how the training went and what we need to improve on, and adjust our trainings to the feedback we receive. This will be followed by the maintance department and the Adminstrator that this rule is being followed.

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

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 231, C 252, C 260, C 270, C 305, C 310, C 363, C 610, and C 613.

• The Administrator conducted a gap analysis and determined which tasks, staff assignments, or deadlines were missed or inadequately tracked. • A meeting was held with department heads and responsible staff to re-review all survey citations and correction strategies to confirm completion and understanding. 2. Systemic Changes to Prevent Recurrence a. POC Implementation Tracking Tool • A formal Plan of Correction Implementation Log was created to track: o Each corrective action item o Responsible party o Target completion date o Date of actual completion o Supporting documentation required for compliance • This log is now maintained by the Administrator or Designee and reviewed weekly during leadership meetings until all items are completed and verified. b. POC Oversight Committee • A temporary oversight team was created to monitor the implementation of all current and future Plans of Correction. • This team includes the Administrator, Resident Care Coordinator(RCC), PSA Supervisor, The RN, Maintance department relevant to each citation area. • Weekly progress updates are logged and discussed until closure is verified and submitted. c. Staff Education • All department heads and supervisory staff were retrained on: o The importance of POC compliance under state regulation o Their responsibilities for executing assigned tasks within the required timeframe o Proper documentation practices and internal deadlines • Going forward, POC training will be included in new leadership orientation and reviewed during annual DHS survey preparedness training. 3. Monitoring and Quality Assurance • POC Status Review Meetings: The Administrator will hold weekly POC status review meetings until all cited items are fully addressed and documented. • Administrative Audit Checklist: A checklist was developed to ensure: o Each element of the POC aligns with the specific citation language o Deadlines are met o Supporting documentation is filed and submitted appropriately • Annual Internal Survey Prep: The facility will now conduct an internal mock survey each year and prepare a mock POC to evaluate readiness and system effectiveness in preventing repeat deficiencies. 4. Responsible Party • Administrator – Responsible for overall oversight of POC compliance, tracking, and reporting. • Administrator and Maintance department– Responsible for executing corrective actions in their assigned areas. • Resident Care Coordintator (RCC) and The RN – Responsible for clinical compliance items and documentation.

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 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory care communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were made of hard, smooth material and maintained in good repair. Findings include, but are not limited to: The exterior of the facility was toured on 10/09/24. The following was identified: * Exterior concrete pathways/sidewalks in the front and sides of the building had multiple areas of broken and/or degrading concrete creating tripping hazards; * Areas of the concrete path/sidewalk had settled and shifted creating uneven pathways and raised seams; and * A 3–4-inch drop-off was visible along a planting bed and walkway in the front of the building. The drop-off created a possible hazard to residents. The building's exterior was toured with Staff 1 (ED) on 10/09/24 at 12:45 pm. She acknowledged the findings. The survey team asked that the areas of broken and degrading concrete be marked to alert residents and/or visitors of the possible tripping hazards. On 10/10/24 at 8:20 am, the survey team observed that orange cones had been placed to ensure residents and visitors were alerted to the uneven concrete walkways.

This rule will be implemented as soon as the facility has the needed funds to redo the sidewalks. We have gotten several bids from different concrete companies to redo the sidewalks. The facility is waiting for the Board of Directors to approve the funding for the sidewalk repair. In the mean time we have the orange cones in place to warn visitors and residents of the danger.The facility will be asking for an extention to fix this. The missing/broken bricks will be fixed by 12/09/2024. This will be followed by the maintenance department and the Administrator.

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory care communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all exterior pathways in the ALF's common-use areas were made of hard smooth material and maintained in good repair. This is a repeat citation. Findings include, but are not limited to: The exterior grounds were toured on 06/03/25 at 9:40 am. The following was identified: * Concrete pathways/sidewalks in front of the building had multiple areas of rough degrading concrete, with uneven surfaces and raised seams; and *The walkways in front of the building showed two to three-inch drop-offs, from the concrete surface to the dirt or bark dust planting beds. These conditions created potential tripping/fall hazards for residents. On 06/03/25 at 1:05 pm, the surveyor showed the areas of concern to Staff 15 (Maintenance Director). He acknowledged the findings. On 06/04/25 at 1:40 pm, the need to ensure all exterior pathways were maintained in good repair was discussed with Staff 1 (ED), Staff 2 (RCC), Staff 3 (Health Services Director), and Staff 4 (Personal Care Assistant Supervisor). They acknowledged the findings.

• Upon receiving the citation, the facility conducted an immediate inspection of all exterior pathways in common-use areas. • Areas identified as cracked, uneven, loose, or deteriorating were marked and restricted from resident use until repaired. • A licensed contractor was contacted and provided a proposal and timeline for repairs to bring all surfaces into compliance. • Temporary safety measures (e.g., signage, cones, alternate access routes) were implemented to prevent resident falls or injuries. 2. Systemic Changes to Prevent Recurrence a. Exterior Pathway Maintenance Plan • The facility developed and implemented an Exterior Pathway Maintenance Plan that includes: o Quarterly inspections of all exterior walkways and patios by the Maintenance Supervisor. o Prompt identification, reporting, and repair of any surface defects or hazards. o Documentation of inspection results, maintenance tickets, and repair dates. b. Vendor and Budget Planning • A preferred vendor agreement was established with a licensed concrete and paving contractor to ensure timely repairs. • The facility allocated funds in the annual maintenance budget specifically for pathway upkeep and emergency repairs. c. Staff Awareness and Reporting • All staff were educated on how to identify and report pathway hazards immediately to the Maintenance Supervisor or Administrator. • A Hazard Reporting Log was established to track environmental concerns and follow-up action. 3. Monitoring and Quality Assurance • Monthly Safety Rounds: The Maintenance Supervisor will conduct monthly environmental safety rounds with documentation focused on: o Exterior pathway integrity o Lighting, drainage, and surface stability o Accessibility for mobility devices • Quarterly QA Review: The QA Committee will review exterior inspection logs and any incident reports related to environmental hazards to identify trends or lapses in maintenance response. • Resident Feedback: Residents will be encouraged to report unsafe walking areas during Resident Council meetings, with all concerns documented and addressed promptly. 4. Responsible Party • Maintenance Supervisor – Responsible for conducting inspections and coordinating repairs. • Administrator – Ensures compliance, budget allocation, and oversight of corrective actions. • QA Committee – Monitors ongoing compliance and effectiveness of the maintenance plan.

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory care communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. 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 ensure all interior surfaces and all equipment necessary for the health, safety, and comfort of the residents was kept clean and in good repair. Findings include, but are not limited to: Observations of the facility on 10/09/24 revealed the following: * Gouged and scraped doors and/or jambs were observed in the following areas: - Resident rooms 101, 102, 103, 107, 113, 116, 117, 121, 122, 123, 124, 126, and 128; - Central bathing room; - Hallway doors near rooms 105 and 123; - Mechanical room; - Medication room; - Beauty shop; - Double doors near beauty shop; and - Dining room. * Carpet in the television room near the entrance, in the hallway leading to dining room, and in the hallway near rooms 115, 116, 120, 121 had several stained areas. * A wall and pillar near the television area and kitchenette had gouged corners; * A dining room wall, located behind the salad bar, had several long, black scraped areas; and * The laundry room cabinet had an approximate three-foot strip of laminate missing from the edge of the countertop. The surveyor toured the environment with Staff 1 (ED) on 10/09/24 at 12:45 pm. She acknowledged the findings.

This rule is being corrected by the maintance department. They have fixed the gouges, scrapes on doors and door jambs by resident rooms, 101, 102, 103, 107,113,116,117,121, 122, 123,124,126,128, central bathing room, hallways near room 105 and 123, mechanical room, medication room, beauty shop, the double doors near beauty shop and the dining room. The stained carpets in the hallways and the dining room. Specifically, hallway near rooms, 115,116,120, 121 have been cleaned. The wall and pillar near the television area and kitchenette gouges have been repaired. The laundry room cabinet with the missing strip of laminate on the edge has been repaired. The housekeeping staff and floor staff will notify the maintenance department of any damage that they find to ensure that it is properly repaired in a timely manner. The maintenance department and the administrator will be responsible for ensuring this rule continues to be met.

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 keep all interior materials and surfaces clean and in good repair. This is a repeat citation. Findings include, but are not limited to: The facility was toured on 06/03/25 at 9:00 am. The following issues were identified: There were gouges and scrapes in the wood of doors and door jambs of resident rooms 113, 117, 121, 122, 123, 124, 126, 128, as well as the doors of the central bathing room, medication room, and double doors near the dining room. On 06/04/25, the areas in need of cleaning or repair were reviewed with Staff 1 (ED) and Staff 15 (Maintenance Director). They acknowledged the findings.

• A full facility-wide inspection was immediately conducted by the Maintenance Supervisor to identify all areas of damaged woodwork and interior surfaces. • All damaged door jambs and doors cited were either: o Repaired, refinished, or repainted, or o Scheduled for replacement if repair was not feasible. • Work orders were generated, and repairs to the most severely damaged areas (including the central bathing room, medication room, and dining room double doors) were prioritized and completed within one month of citation. • Resident and staff safety was maintained during repair work with proper signage and containment of dust or debris. 2. Systemic Changes to Prevent Recurrence a. Routine Maintenance Plan • The facility implemented a quarterly environmental maintenance inspection checklist that includes: o Condition of doors, door frames, baseboards, and other wood surfaces o Cleanliness and integrity of walls, flooring, and common surfaces • The Maintenance Supervisor is now responsible for documenting and addressing all cosmetic and structural interior concerns found during these inspections. b. Work Order and Follow-Up System • A formal work order system was reinforced with updated procedures that require: o All staff to report damage or wear to interior surfaces as soon as identified. o Maintenance to respond within 72 hours to assess and prioritize repair needs. o All repairs to be documented and verified upon completion. c. Staff Education • Housekeeping, caregiving, and maintenance staff were retrained on: o Their role in early detection and reporting of environmental wear and damage. o How to document and escalate issues using the facility’s work order system. o Maintaining cleanliness and reporting damage during daily tasks. 3. Monitoring and Quality Assurance • Monthly Interior Quality Checks: The Administrator and Maintance director will walk the facility monthly using a standardized checklist to ensure: o All surfaces are clean and in good repair o High-traffic areas are being monitored for accelerated wear and tear • Quarterly QA Committee Review: All work order trends related to environmental maintenance will be reviewed quarterly by the QA Committee to evaluate response timeliness and identify recurring problem areas. • Resident and Family Feedback: The facility will encourage residents and family members to provide feedback regarding cleanliness and interior conditions during Resident Council meetings or through suggestion forms. 4. Responsible Party • Maintenance Supervisor – Responsible for inspections, timely repairs, and documentation. • Administrator – Oversees the effectiveness of the corrective actions and ensures proper follow-through on maintenance needs. • Housekeeping – Assists in identifying areas in need of repair during routine cleaning.

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:

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (c) Each resident record must, before move-in and when updated, include the following information: (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (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. This Rule is not met as evidenced by: Based on interview and record review, the facility failed to ensure the move-in evaluation addressed all required elements, including pronouns and gender identity, for 1 of 1 resident (# 7) whose move-in evaluation was reviewed. Findings include, but are not limited to: Refer to: C 252.

• The facility conducted an immediate audit of all existing resident move-in evaluations to determine if pronouns and gender identity were documented. • Residents whose evaluations were missing this information were respectfully approached by trained staff to obtain and document their preferred pronouns and gender identity in accordance with their wishes and privacy rights. • The evaluations were updated, and care team members were informed as appropriate to ensure respectful, individualized care. 2. Systemic Changes to Prevent Recurrence a. Revision of Move-In Evaluation Forms • The move-in evaluation form was revised to include clearly labeled, mandatory fields for: o Preferred name o Pronouns (e.g., he/him, she/her, they/them, other) o Gender identity (self-identified) • These fields are now a required component of the intake process and cannot be skipped or left blank without resident refusal, which must be documented. b. Staff Training and Cultural Competency • All staff involved in admissions, care planning, and direct care received retraining on: o The importance of collecting and honoring gender identity and pronouns o Trauma-informed and respectful communication when discussing personal identity o How to document this information accurately and sensitively in the resident record • Ongoing LGBTQ+ cultural competency training will now be included in annual education for all staff. c. Admission Process Improvements • A new admission checklist now includes verification that: o All personal identity fields are completed or refusal is documented o Staff conducting the intake has confirmed resident understanding and comfort 3. Monitoring and Quality Assurance • Admission Record Audit: The Resident Care Coordinator (RCC) and Medical Records will review 100% of new move-in files within 48 hours of admission to verify the inclusion of all required fields. • Quarterly Record Review: The QA Committee will conduct a quarterly audit of 10% of resident files to ensure ongoing compliance and evaluate staff consistency in capturing personal identity information. • Resident Satisfaction Feedback: Residents will be given the opportunity during care conferences or satisfaction surveys to confirm the respectful use of their pronouns and identity. 4. Responsible Party • Resident Care Coordinator (RCC) – Oversees compliance with move-in evaluation documentation. • The RN and RCC– Ensures all required personal identity elements are addressed during initial assessments. • Administrator – Responsible for oversight of training, compliance systems, and quality assurance audits.

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (c) Each resident record must, before move-in and when updated, include the following information: (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (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. This Rule is not met as evidenced by: