Print Inspection: RL000909

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to promptly investigate incidents to rule out abuse or neglect and report incidents to the local Seniors and People with Disabilities (SPD) office, if abuse or neglect could not be ruled out, for 1 of 2 sampled residents (#4) who had a modified diet and an unwitnessed injury fall. Findings include, but are not limited to: Resident 4 was admitted to the facility in 05/2023 with diagnoses including essential hypertension, syncope and collapse, urinary incontinence, degenerative disease of nervous system, and right knee pain. Resident 4’s progress notes and temporary service plans dated 07/02/24 through 10/19/24, physician orders, and incident reports were reviewed, the following was identified: a. The resident’s initial physician order for a mechanical soft diet was dated 05/17/24. A progress note, dated 07/17/24, identified the resident “…[choked] on [his/her] dinner because the kitchen provided solid foods when resident [was] on a mechanical soft diet.” There was no documented evidence the facility promptly investigated this incident to rule out abuse or neglect or that the incident was reported to the local SPD office. On 10/23/24 at 11:34 am, Staff 3 (Associate Wellness Director) and Staff 4 (Resident Service Director) confirmed the incident was not investigated or reported to local SPD. b. An incident report dated 09/11/24 indicated the resident had an unwitnessed fall with a head injury on 09/10/24 and was sent to the emergency department. A temporary service plan indicated the resident returned to the facility on 09/12/24. The investigation dated 09/18/24 revealed an investigation was not completed promptly to rule out abuse and neglect and did not have documentation for all required components. Additionally, the incident was not reported to local SPD. On 10/23/24 at 11:34 am, the documented investigation was reviewed with Staff 3 and Staff 4. They acknowledged the lack of information documented in the investigation and confirmed this incident was not reported to local SPD. The facility was asked to report both events to the local SPD office prior to survey exit. The need to promptly investigate injuries of unknown cause with all required components and report the incidents to the local SPD office if abuse or neglect could not be ruled out was discussed with Staff 1 (ED) on 10/23/24 at 12:58 pm. She acknowledged the findings.

1. The incident from 5/12/2024 and from 9/11/2024 both regarding resident #4 have been reported to the local SPD office. 2. Each working morning the ED, WD and/or the AWD will review and investigate incident reports to see if abuse/neglect can be ruled out then sent to APS if needed. They will also review alert charting to see if something is needing an incident report that doesn't have one. 3. Each working day of the ED, WD and/or the AWD. 4. ED, WD and AWD.

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 411-054-0036 (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 provided clear direction regarding the delivery of services or were implemented for 1 of 5 sampled residents (# 4) whose service plans were reviewed. Findings include, but are not limited to: Resident 4 was admitted to the facility in 05/2023 with diagnoses including essential hypertension, syncope and collapse, urinary incontinence, degenerative disease of nervous system, and right knee pain. Observations were made of the resident's care from 10/21/24 through 10/23/24. Interviews with the resident, facility staff, and the resident outside provider were conducted. The current service plan dated 10/08/24 was reviewed and the following was identified: Resident 4's service plan lacked clear instruction and/or was not implemented in the following areas: * Instruction for use and safety monitoring of bilateral side rails; * Instruction and location of resident’s pain including non-pharmaceutical interventions; * Resident specific interventions for seasonal affective disorder including current interests and abilities; * Hospice services provided including RN and LPN involvement and massage and music therapy; * Frequency of toileting and incontinence checks; and * Escorts to and from dining room for meals. The need to ensure the service plan provided clear instruction regarding the delivery of services and services were implemented, was discussed with Staff 1 (ED) on 10/23/24 at 12:58 pm. She acknowledged the findings.

1. Careplan for resident #4 was updated regarding instructions for use and safety monitoring of bilateral side rails, instruction and location of residen's pain including non-pharmaceutical interventions, resident specific interventions for seasonal affective disorder including current interests and abilities, hospice services provided including RN and LPN involvement and massage and music therapy, frequency of toileting and incontinence checks and escorts to and from dining room for meals. 2. Any change regarding the resident and/or a plan of care a TSP will be completed and become part of the careplan. 3. Quarterly, significant change and/or PRN 4. AWD and ED.

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 provided clear direction regarding the delivery of services or were implemented for 1 of 4 sampled residents (# 8) whose service plans were reviewed. This is a repeat citation. Findings include but are not limited to: Resident 8 was admitted to the facility in 12/2022 with diagnoses including atrial fibrillation, hypertension, and cardiomyopathy. Observations, interviews, and review of the resident record were completed on 1/22/25 and 1/23/25. The following was identified: Resident 8's service plan was not current, lacked clear instruction and/or was not implemented in the following areas: *Service plan was not updated quarterly. On 1/23/25 the most current service plan available for staff was dated 10/17/24; *Significant weight loss in 12/24; *Two falls in 12/24; *Hospice status and home health services; *Independent ambulation and ability to push another resident in their wheelchair; and *Independent ADL ability including showers, toileting, and dressing. The need to ensure the service plan was updated and provided clear instruction regarding the delivery of services was discussed with Staff 1(Executive Director) and Staff 2 (Resident Services Director) on 1/13/25. They acknowledged the findings.

1. Service plan for resident number 8 was updated regarding admitting to hospice, recent falls and hospice assists with bathing was added. The ability to push another resident in their wheelchair was removed. 2. Prior to updating service plan RSD or WD to communicate with care staff and inquire about any services changes as well as assessing the resident. 3. 30-day assessment, 90-day assessment, change of condition and as needed. 4. Resident Services Director and Wellness Director.

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

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents who had significant changes of condition were evaluated, referred to the RN for an assessment and service plans updated as needed and failed to determine and document what action or interventions were needed for residents, actions or interventions communicated to staff on each shift and progress noted at least weekly through resolution for 2 of 5 sampled residents (#s 2 and 4) reviewed with changes of condition. Findings include, but are not limited to: Resident 2 was admitted to the facility in 11/2021 with diagnoses including Alzheimer’s disease. Interviews and reviews of the resident's 07/18/24 through 10/19/24 progress notes, 08/26/24 service plan, temporary service plans and physician’s orders revealed the resident experienced the following short-term changes of condition: * 07/19/24 - Bump to the head and skin tear to right arm; * 08/23/24 - Friction area to right medial thigh; * 08/30/24 – Suicidal ideation; * 09/12/24 – Aggressive behaviors; * 09/13/24 – Medication order changes: discontinue hydrocodone-acetaminophen 5-325 mg (for pain) every six hours, start hydrocodone-acetaminophen 10-325 mg every six hours, start dermaseptin (for skin irritation) twice daily, start haloperidol lacate 2 mg/ml (for agitation and hallucinations); * 09/16/24 – Medication order change: discontinue haloperidol lactate 2 mg/ml three times daily; and * 09/19/24 – Medication order changes: start haloperidol lactate 2 mg/ml two times daily, discontinue hydrocodone-acetaminophen 10-325 mg every six hours while awake, start hydrocodone-acetaminophen 7.5-325 mg every six hours while awake, discontinue mirtazapine 45 mg (for depression) every evening, start mirtazapine 30 mg every evening. There was no documented evidence the facility determined and documented resident specific actions or interventions needed related to the skin concerns, suicidal ideation, behaviors or medications order changes, communicated interventions to staff on each shift, or monitored the conditions with the progress noted at least weekly through resolution. The need to ensure residents who experienced short term changes of condition were evaluated to determine if actions or interventions were needed, actions or interventions were communicated to staff on each shift and documented at least weekly with progress noted until the condition resolved was discussed with Staff 1 (ED) on 10/23/24 at 12:12pm. She acknowledged the findings. C270: BW - example 2. Resident 4 was admitted to the facility in 05/2023 with diagnoses including essential hypertension, syncope and collapse, urinary incontinence, degenerative disease of nervous system, and right knee pain. Clinical records, including the current service plan, dated 10/08/24, and progress notes dated, 07/02/24 through 10/19/24, were reviewed. Interviews with the resident and staff were conducted, the following was identified: The following short-term change of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and documented weekly progress until the condition resolved: * 07/17/24 - Resident 4 “…[choked] on [his/her] dinner because the kitchen provided solid foods when resident [was] on a mechanical soft diet.” The need to ensure the facility determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was discussed with Staff 1 (ED) on 10/23/24 at 12:58 pm. She acknowledged the findings.

1. Medication changes have been updated and verified with hospice for resident #2 and resident #4. Verified diet orders for resident number #4 with DSD. Skin sheets were reviewed for resident #4 to ensure all current skin issues are being followed. 2. Skin log is being use for all current skin concern until resolved. RSD and hospice had a conversation on how order changes will be communitcated. AWD and WD will conversate with DSD with all diet orders changes. 3. Daily and as needed. 4. AWD and WD.

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 residents who had changes of condition were evaluated and referred to the RN for an assessment for 1 of 4 sampled residents (#8) reviewed with changes of condition. This is a repeat citation. Findings include, but are not limited to: Resident 8 was admitted to the facility in 12/2022 with diagnoses including atrial fibrillation, hypertension, and cardiomyopathy. Interviews and reviews of the resident's 12/22/24 through 1/23/25 progress notes, 10/17/24 service plan, temporary service plans and physician’s orders revealed: The 12/23/24 “Weights and vitals summary” showed Resident 8 was weighed at 9:17 am and weighed 144.8 lbs. The electronic documented automatically noted “Warning: change (comparison weight 12/04/24, 153 lbs, -5.4%, -8.2 lbs) - indicating Resident 8 had lost over 5% of their body weight in less than 30 days. The next day Resident 8 was weighed at 144.3 lbs, confirming the weight loss and again triggering a warning. The weight loss was not evaluated, not referred to the RN for assessment, and the service plan was not updated. Meal observations on 1/22/25 and 1/23/25 showed Resident 8 eating independently in the dining room, with approximately 75% of the meal consumed each time. Resident 8 was weighed on 01/13/25 at 148 lbs. The need to evaluate changes of condition and refer to the facility RN for assessment was discussed with Staff 1 (Executive Director) and Staff 2 (Resident Services Director) on 1/23/25. They acknowledged the findings.

1. Resident number 8 who was admitted to hospice and had weight loss has had a significant change of condition assessment completed. 2. Significant changes will be reported to RN as soon as possible and within the 48-hour window. All significant change of condition assessments will be completed by RN within 48 hours. Resident Servies Director and Wellness Director to follow up to ensure the assessment is done within 48 hours. 3. Weekly, monthly and needed. 4. Resident Services Director and Wellness Director.

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

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

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an RN completed a timely assessment that documented findings, resident status, and interventions made as a result of the assessment for 1 of 2 sampled residents (#3), who experienced significant changes of condition. Findings include, but are not limited to: Resident 3 moved into the facility in 03/2023 with diagnoses including atrial fibrillation and unspecified dementia. a. Progress notes dated 06/27/24 to 10/19/24 and weight records from 04/14/24 to 08/16/24 were reviewed during the survey. Weight records reviewed identified the following: * 04/14/24 -135 pounds; * 06/14/24 – 140 pounds; * 07/12/24 – 148 pounds; and * 08/16/24 – 135.2 pounds. Between 04/14/24 and 07/12/24 Resident 3 gained 13 pounds or 9.62 % total body weight within three months. This constituted a severe weight gain which required an RN assessment. There was no documented evidence an RN completed an assessment for the severe weight gain. During an interview with Staff 2 (RN) on 10/22/24 confirmed she had not completed an assessment for the weight gain identified on 07/12/24. Staff 2 stated she was aware of the weight gain and had contacted the resident’s physician. Between 07/12/24 and 08/16/24 the resident lost 12.8 pounds or 8.65% total body weight within one month. This constituted a severe weight loss within one month which required an RN assessment. Staff 2 completed an untimely RN assessment on 09/06/24. b. Resident 3 went to the emergency room on 08/16/24 and returned on 08/23/24 with a new diagnosis. Staffed documented in progress notes the following information: * On 08/26/24 – “Resident had slight difficulty swallowing pills”; * On 08/26/24 – “Resident stated the [s/he] feels different than before”; * On 08/29/24 – “[Resident] said [s/he] is too sick to get up and shower”; * On 08/31/23 – “Resident has been having full incontinence of [his/her] bladder and bowels in [his/her] bed. This is not baseline [s/he] is usually able to tell when [s/he] needs to use the restroom, this started when [s/he] came home from the hospital on 08/23/24”; and * On 09/01/24 – “Resident has been urinating and having BM’s [bowel movements] and not calling staff to let them help, this has been going on for several days now and is not usual for [him/her].” Resident 3 had a second emergency room visit on 09/27/24 and returned on 10/02/24 with a new diagnosis including respiratory failure and was referred to hospice services. The decline in health status and ADL ability documented on 08/23/24 constituted a significant change on condition that required an RN assessment. There was no documented RN assessment completed until the resident was admitted to hospice services on 10/04/24. The need to ensure RN assessments for residents who experienced significant changes of condition were done timely and included documentation of findings, resident status, condition and any interventions made as a result of the assessment was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (Associate Wellness Director) on 10/23/24 at 10:58 am. They acknowledged the findings.

1. Resident #3 is no longer a resident. After all ED visit an assessment will be completed to see if an sigfication change of condtion is needed. All residents weights are being taken. 2. After all ED visit an assessment will be completed to see if an sigfication change of condtion is needed. If an abnornal wieght has been detected a license nurses will retake the weight. 3. Return rom ED, monthly and as needed. 4. WD and RN

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an RN completed a timely assessment that documented findings, resident status, and interventions made as a result of the assessment for 1 of 2 sampled residents (#8), who experienced significant changes of condition. This is a repeat citation. Findings include but are not limited to: Resident 8 was admitted to the facility in 12/2022 with diagnoses including atrial fibrillation, hypertension, and cardiomyopathy. Interviews and reviews of the resident's 12/22/24 through 1/23/25 progress notes, 10/17/24 service plan, temporary service plans and physician’s orders revealed: The 12/23/24 “Weights and vitals summary” showed Resident 8 was weighed at 9:17 am and weighed 144.8 lbs. The electronic documented automatically noted “Warning: change (comparison weight 12/04/24 = 153 lbs, -5.4%, -8.2 lbs)” - indicating Resident 8 had lost over 5% of their body weight in less than 30 days. There was no documented evidence an RN assessed the significant weight loss. There were no updates to Resident 8’s service plan or interventions developed. Meal observations on 1/22/25 and 1/23/25 showed Resident 8 eating independently in the dining room, with aproximately 75% of the meal consumed in each instance. Resident 8 was weighed on 01/13/25 at 148 lbs. The need to ensure RN assessments for residents who experienced significant changes of condition was discussed with Staff 1 (Executive Director) and Staff 2 (Resident Services Director) on 01/23/25. They acknowledged the findings.

1. Weekly RN notes and interventions have been docuemnted since the significant change of condition was identified for resident #8. 2. Review notes and changes of conditions weekly and as needed. Ensure new intereventions are put on the service plan 3. Weekly and as needed. 4. Resident Services Director and Executive Director.

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

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

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 2 of 5 sampled residents (#s 2 and 4) whose records were reviewed. Findings include, but are not limited to: Resident 4 was admitted to the facility in 05/2023 with diagnoses including essential hypertension, syncope and collapse, urinary incontinence, degenerative disease of nervous system, and right knee pain. The resident's 10/2024 MAR and most recent physician orders were reviewed and the following was identified: The resident had a 10/08/24 order to discontinue the following: * Melatonin 3mg (for insomnia); * Senexon-s 3mg (for constipation); * Sertraline hcl 100mg (for depression); and * Travoprost 0.004% eye drops (for glaucoma). The facility continued to administer the medication daily through 10/21/24 without a signed physician’s order. On 10/22/24 at 1:01 pm, Staff 3 (Associate Wellness Director) and Staff 4 (Resident Service Director) confirmed the above listed medications and treatment were administered without a current physician order. The need to ensure orders were carried out as prescribed was discussed with Staff 1 (ED) on 10/23/24 at 12:58 pm. She acknowledged the findings. 2. Resident 2 was admitted to the facility in 11/2021 with diagnoses including Alzheimer’s Disease. The resident's signed physician orders and 09/01/24 through 10/21/24 MARs were reviewed, and the following was identified: The resident had a 09/16/24 order to discontinue Loratadine 10 mg (for eye itchiness). The facility continued to administer the medication daily through 10/22/24 without a signed physician’s order. Staff 4 (Resident Services Director) was interviewed on 10/22/24 and was not able to provide any additional information. A 10/23/24 MAR was provided showing the medication had been removed from the MAR. The need to ensure all medication and treatment orders were carried out as prescribed was reviewed with Staff 1 (ED) on 10/23/24 at 12:12 pm. She acknowledged the findings.

1. RSD and hospice clearified orders for resident #2 and resident #4. RSD and hospice had a conversation and how order changes will be communitcated. 2. It was been agreed with hospice that they will send over a specific DC'd order. 3. With every med order fax. 4. RSD, AWD and WD.

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 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure newly hired direct care staff completed the required pre-service infectious disease prevention training and pre-service dementia training prior to beginning job responsibilities for 4 of 4 newly-hired staff (#s 16, 17, 18 and 19). Findings include, but are not limited to: The facility's training records were reviewed with Staff 20 (Business Office Manager) on 10/23/24. The following was noted: a. There was no documented evidence Staff 16 (Care Associate) hired on 06/24/24, Staff 17 (Care Associate) hired 08/19/24 and Staff 19 (Care Associate) hired 07/17/24 completed the department approved Infectious Disease Prevention training prior to beginning their job responsibilities. b. There was no documented evidence Staff 16, Staff 17, Staff 18 (Care Associate/MT) hired 08/23/23 and Staff 19 completed the required pre-service dementia training in specific aspects of dementia including pain, proving food/fluids, preventing wandering, use of person-centered approach prior to beginning their job responsibilities. The requirements for pre-service training for all employees were reviewed with Staff 1 (ED) and Staff 20 on 10/23/24 at 12:12 pm. They acknowledged the findings.

1. An aduit of all employee hired after 07/30/2023 was completed.The date was selected due to on 8/1/2023 how we assigned needed training was updated. 2. BOM will assign training to the new employees, once the BOM believes they have assigned all training they will complete an audit of the new employees training to ensure all training was assigned. Once the new hire has completed the assigned training the ED will complete an aduit to ensure all state required training is completed. 3. With every new hire. 4. BOM and ED

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by:

OAR 411-054-0070 (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 newly hired staff demonstrated satisfactory performance in all required areas within the first 30 days of hire for 4 of 4 direct care staff (#s 16, 17, 18 and 19). Findings include, but are not limited to: Facility training records were reviewed with Staff 20 (Business Office Manager) on 10/23/24. The following was noted: Staff 16 (Care Associate) hired on 06/24/24, Staff 17 (Care Associate) hired 08/19/24 and Staff 19 (Care Associate) hired 07/17/24 lacked documented evidence of demonstrated satisfactory performance within 30 days of hire in the following area: * Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. Staff 16, 17, 19 and Staff 18 (Care Associate/MT) hired 08/23/23 lacked documented evidence of demonstrated satisfactory performance within 30 days of hire in the following areas: * Changes associated with normal aging; and * Conditions that require assessment, treatment, observation and reporting. The need to ensure new hire staff demonstrated satisfactory performance in all required areas within the first 30 days of hire was discussed with Staff 1 (ED) and Staff 20 on 10/23/24 at 12:12 pm. They acknowledged the findings.

1. A demonstrated satisfactory form will be used that will verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. 2. The demonstarated satisfactory will be reviewed for every new direct care staff at 30 days of hire. 3. With every new direct care staff. 4. RSD and BOM.

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

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to conduct unannounced fire drills according to the Oregon Fire Code (OFC) and failed to provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to: Fire and life safety records from 04/2024 through 09/2024 were reviewed with Staff 11 (Plant Operations Director) on 10/23/24 at 9:20 am and the following was identified: a. Fire drill records lacked consistent documentation of one or more of the following required elements: * Location of simulated fire origin; * Escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; * Evacuation time period needed; * Staff members on duty; * Number of occupants evacuated; and * Evidence alternate routes were used during fire drills. b. There was no documented evidence the facility provided fire and life safety training to staff on alternate months. c. The 07/02/24 fire drill was not conducted in the assisted living facility and the 09/02/24 fire drill did not document if it was conducted in the assisted living or memory care facility. The need to ensure the facility conducted unannounced fire drills according to the OFC and provided fire and life safety instruction to staff on alternate months was discussed with Staff 1 (ED) on 10/23/24 at 10:10 am. She acknowledged the findings.

1. Every other months when completing fire drills we will have one take place in Assisted Living only. The documentation will include location of simulated fire origin, escape route used, problems encountered, comments relating to residents who resisted or failed to particiapte in the drills, evacuation time period needed, staff membert on duty, number of occupants evacuated and evidence alternate routes that were used. 2. The months that fire drills are completed POD is to turn in fire drill documentation to BOM who will ensure all information is completed on the form. 3. Every other month. 4. POD and BOM.

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

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

Refer to C260, C270 and C280.

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 accessible and maintained in good repair. Findings include, but are not limited to: On 10/21/24 at 9:05 am the exterior of the facility was toured. The following was identified: * The courtyard had drop-offs which measured up to five inches along the paved pathways located around the perimeter of the resident use recreation area where horseshoes and the outdoor pet area were located. Residents were observed walking in these areas during the survey. The drop offs created a tripping hazard for residents. * On 10/21/24 and 10/22/24 there was two mattresses, two recliner chairs, a broken television, durable medical equipment and a discarded file cabinet around the garbage area. On 10/22/24 at 11:48m, the exterior of the facility and the recreation area was toured with Staff 1 (ED) and Staff 11 (Plant Operations Director). They acknowledged the drop offs, and the need to ensure garbage and refuse was stored in covered containers.

1. Bark chips were purchased and spread to ensure that are no longer drop-offs that could case a tripping hazards for the residents. The two mattresses, two recliner chairs, a broken television, durable medical equipment and a discarded file cabinet have all been removed. Reminders to all staff regarding the coverage of the garage and cardboard containers. 2. Weekly walk throughs will include any drop off area and coverage of the garage and cardboard container. 3. Weekly. 4. POD and ED.

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 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 residents was kept clean and in good repair. Findings include, but are not limited to: During a tour of the interior and exterior environment on 10/21/24 at 9:05 am the following was observed: * There was an approximate three-foot crack in the windowpane that hung above an entrance door in the stairwell that led to the memory care entrance and to the second floor of the assisted living. * There was a build up of moss and lint from two dryer vents that had accumulated on the exterior siding and an exit door that led to a resident use recreation area. The need to ensure the interior and exterior environment was clean and in good repair was discussed with Staff 1 (ED) and Staff 11 (Plant Operations Director) on 10/22/24 at 11:48 am. They acknowledged the findings.

1. Windowpane has been measured for replacement and will be replaced soon. The moss and lint from the two dryer vents have been removed. 2. During on weekly walk through we will look for cracked windows, moss and lint from dryers. 3. Weekly. 4. POD and ED.

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 411-054-0300 (5) Resident Units (5) RESIDENT UNITS. All resident units must be accessible per building codes. These apartments must have a lockable entry door with lever type handle, a private bathroom, and kitchenette facilities. Adaptable units are not acceptable.(a) UNIT DIMENSIONS. New construction units must have a minimum of 220 net square feet, not including the bathroom. Units in pre-existing structures being remodeled must have a minimum of 160 square feet, not including the bathroom.(b) RESIDENT STORAGE SPACE.(A) Each unit must provide usable space totaling at least 100 cubic feet for resident clothing and belongings and include one clothes closet with a minimum of four linear feet of hanging space.(B) The rod must be adjustable for reach ranges per building codes. In calculating useable space, closet height may not exceed eight feet and a depth of two feet.(C) Kitchen cabinets must not be included when measuring storage space.(D) A lockable storage space (e.g., drawer, cabinet, or closet) must be provided for the safekeeping of a resident ' s small valuable items and funds. Both the administrator and resident may have keys.(c) WINDOWS.(A) Each resident's living room and bedroom must have an exterior window that has an area at least one-tenth of the floor area of the room.(B) Unit windows must be equipped with curtains or blinds for privacy and control of sunlight.(C) Operable windows must be designed to prevent accidental falls when sill heights are lower than 36 inches and above the first floor.(d) DOORS. Each unit must have an entry door that does not swing into the exit corridor.(A) A locking device must be included that is released with action of the inside lever. Locks for the entry door must be individually keyed, master keyed, and a key supplied to the resident.(B) The unit exit door must open to an indoor, temperature controlled, common-use area or common corridor.(e) BATHROOM. The unit bathroom must be a separate room with a toilet, sink, a roll-in curbless shower, towel bar, toilet paper holder, mirror, and storage for toiletry items.(A) The door to the bathroom must open outward or slide into the wall.(B) Showers must have a slip-resistant floor surface in front of roll-in showers, a hand-held showerhead, cleanable shower curtains, and appropriate grab bar.(f) KITCHENS OR KITCHENETTES. Each unit must have a kitchen area equipped with the following:(A) A sink, refrigerator, and cooking appliance that may be removed or disconnected. A microwave is considered a cooking appliance.(B) Adequate space for food preparation.(C) Storage space for utensils and supplies.(D) Counter heights may not be higher than 34 inches. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure a lockable storage space and/or key was provided for the safekeeping of residents' small valuable items and funds for multiple sampled and unsampled residents. Findings include, but are not limited to: * On 10/22/24 at 9:10 am, six unsampled resident units were toured and residents that were interviewed confirmed they didn’t have a lockable storage space in their apartments, or they did not have a key to the storage space. * Sampled residents (#’s 3 and 5) confirmed during interviews and observations that they did not have a key for the lockable storage in their units. The need to ensure residents had lockable storage space and a key to secure valuable items was discussed with Staff 1 (ED) on 10/23/24 at 10:48 am. She acknowledged the findings.

1. An inspection will be completed to identify what apartments do not have a lockable storage space. We will then supply all needed apartments with the lockable storage space. 2. Upon tunovers we will ensure there is a lockable storage space in the apartment. If the resident does not want the lockage storage space it will be noted in the residents business file. 3. An annual inspection will be completed and during apartment turnover. 4. POD and ED.

OAR 411-054-0300 (5) Resident Units (5) RESIDENT UNITS. All resident units must be accessible per building codes. These apartments must have a lockable entry door with lever type handle, a private bathroom, and kitchenette facilities. Adaptable units are not acceptable.(a) UNIT DIMENSIONS. New construction units must have a minimum of 220 net square feet, not including the bathroom. Units in pre-existing structures being remodeled must have a minimum of 160 square feet, not including the bathroom.(b) RESIDENT STORAGE SPACE.(A) Each unit must provide usable space totaling at least 100 cubic feet for resident clothing and belongings and include one clothes closet with a minimum of four linear feet of hanging space.(B) The rod must be adjustable for reach ranges per building codes. In calculating useable space, closet height may not exceed eight feet and a depth of two feet.(C) Kitchen cabinets must not be included when measuring storage space.(D) A lockable storage space (e.g., drawer, cabinet, or closet) must be provided for the safekeeping of a resident ' s small valuable items and funds. Both the administrator and resident may have keys.(c) WINDOWS.(A) Each resident's living room and bedroom must have an exterior window that has an area at least one-tenth of the floor area of the room.(B) Unit windows must be equipped with curtains or blinds for privacy and control of sunlight.(C) Operable windows must be designed to prevent accidental falls when sill heights are lower than 36 inches and above the first floor.(d) DOORS. Each unit must have an entry door that does not swing into the exit corridor.(A) A locking device must be included that is released with action of the inside lever. Locks for the entry door must be individually keyed, master keyed, and a key supplied to the resident.(B) The unit exit door must open to an indoor, temperature controlled, common-use area or common corridor.(e) BATHROOM. The unit bathroom must be a separate room with a toilet, sink, a roll-in curbless shower, towel bar, toilet paper holder, mirror, and storage for toiletry items.(A) The door to the bathroom must open outward or slide into the wall.(B) Showers must have a slip-resistant floor surface in front of roll-in showers, a hand-held showerhead, cleanable shower curtains, and appropriate grab bar.(f) KITCHENS OR KITCHENETTES. Each unit must have a kitchen area equipped with the following:(A) A sink, refrigerator, and cooking appliance that may be removed or disconnected. A microwave is considered a cooking appliance.(B) Adequate space for food preparation.(C) Storage space for utensils and supplies.(D) Counter heights may not be higher than 34 inches. This Rule is not met as evidenced by:

OAR 411-054-0300 (7)(b-d) House Keeping and Sanitation (b) HOUSEKEEPING AND SANITATION.(A) An ALF must have a secured janitor closet for storing supplies and equipment, with a floor or service sink.(B) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.(c) LAUNDRY FACILITIES. Laundry facilities may be located to allow for both resident and staff use when a time schedule for resident-use is provided and equipment is of residential type.(A) If the primary laundry facility is not suitable for resident-use, an ALF must provide separate resident laundry facilities.(B) Laundry facilities must be separate from food preparation and other resident-use areas.(C) On-site laundry facilities, used by staff for facility and resident laundry, must have capacity for locked storage of chemicals and equipment.(D) An ALF must provide covered or enclosed clean linen storage that may be on shelves or carts. Clean linens may be stored in closets outside the laundry area.(E) The wall base of the laundry facilities must be continuous and coved with the floor, tightly sealed to the wall and constructed without voids that may harbor insects or moisture.(d) SOILED LINEN PROCESSING. For the purpose of this rule, "soiled linens and soiled clothing," means linens or clothing contaminated by an individual's bodily fluids (for example, urine, feces, and blood).(A) There must be a separate area with closed containers that ensure the separate storage and handling of soiled linens and soiled clothing. There must be space and equipment to handle soiled linen and soiled clothing processing needs that is separate from regular linen and clothing.(B) Arrangement must provide a one-way flow of soiled linens and soiled clothing from the soiled area to the clean area and preclude potential for contamination of clean linens and clothing.(C) The soiled linen area must include a flushing rim clinical sink with a handheld rinsing device and a hand wash sink or lavatory.(D) When washing soiled linens and soiled clothing, washers must have a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant is used.(E) Personnel handling soiled laundry must be provided with waterproof gloves.(F) Covered or enclosed clean linen storage must be provided and may be on shelves or carts. Clean linens may be stored in closets outside the laundry area.(G) The wall base of the laundry facilities must be continuous and coved with the floor, tightly sealed to the wall and constructed without voids that may harbor insects or moisture. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure soiled clothing and linens were laundered in a machine with a minimum rinse temperature of 140 degrees Fahrenheit or with a chemical disinfectant, provided a separate area with closed containers for soiled linens, provided a schedule for resident use, and provided a one way flow of soiled linens and clothing that precludes the potential for contamination of clean linens and clothing. Findings include, but are not limited to: A tour of two facility laundry rooms on 10/21/24 at 9:05 am, identified the following: * Both laundry rooms had residential washing machines and dryers, with a utility sink and one point of entry; * The detergent being used within the community laundry rooms did not have a chemical disinfectant included; * The laundry rooms were simultaneously shared by residents and staff with no identified schedule for resident use; * There was not a locked storage area for chemicals and equipment; and * No identified one-way flow of soiled linens and clothing. During an interview and observation on 10/21/24 at 1:45 pm with Staff 7 (Care Associate) the process for handling soiled clothing and linens was as follows: “I put on gloves and put it in a trash bag and rinse it out in the slop sink [utility sink]. If the washers are full then I put it back in a bag and set it over there [pointing to the corner of the laundry room]. I like to take a wad of paper towel and wipe the interior of the washing machine. If nothing brown comes off, then I’m good to go to put another resident’s laundry in the washer.” During an interview on 10/21/24 at 10:45 am, Staff 11 (Plant Operation Director) reported the laundry rinse temperature was less than 140 degrees and there was no chemical disinfectant used. The need to ensure the facility properly laundered soiled resident linens and clothing and meet housekeeping and sanitation requirements was reviewed with Staff 1 (ED) and Staff 11 on 10/21/24 at 10:45 am. They acknowledged the findings.

1. It has been determine that the small laundry room will be designated for soiled laundry. A chemical disinfectant has been ordered. 2. Training will be provided regaring how to transport soild laundry, how much of the chemical disinfectant to use and how to clean the machine when cycle is completed. 3. As new employees are hired and as needed. 4. POD, RDS and ED.

OAR 411-054-0300 (7)(b-d) House Keeping and Sanitation (b) HOUSEKEEPING AND SANITATION.(A) An ALF must have a secured janitor closet for storing supplies and equipment, with a floor or service sink.(B) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.(c) LAUNDRY FACILITIES. Laundry facilities may be located to allow for both resident and staff use when a time schedule for resident-use is provided and equipment is of residential type.(A) If the primary laundry facility is not suitable for resident-use, an ALF must provide separate resident laundry facilities.(B) Laundry facilities must be separate from food preparation and other resident-use areas.(C) On-site laundry facilities, used by staff for facility and resident laundry, must have capacity for locked storage of chemicals and equipment.(D) An ALF must provide covered or enclosed clean linen storage that may be on shelves or carts. Clean linens may be stored in closets outside the laundry area.(E) The wall base of the laundry facilities must be continuous and coved with the floor, tightly sealed to the wall and constructed without voids that may harbor insects or moisture.(d) SOILED LINEN PROCESSING. For the purpose of this rule, "soiled linens and soiled clothing," means linens or clothing contaminated by an individual's bodily fluids (for example, urine, feces, and blood).(A) There must be a separate area with closed containers that ensure the separate storage and handling of soiled linens and soiled clothing. There must be space and equipment to handle soiled linen and soiled clothing processing needs that is separate from regular linen and clothing.(B) Arrangement must provide a one-way flow of soiled linens and soiled clothing from the soiled area to the clean area and preclude potential for contamination of clean linens and clothing.(C) The soiled linen area must include a flushing rim clinical sink with a handheld rinsing device and a hand wash sink or lavatory.(D) When washing soiled linens and soiled clothing, washers must have a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant is used.(E) Personnel handling soiled laundry must be provided with waterproof gloves.(F) Covered or enclosed clean linen storage must be provided and may be on shelves or carts. Clean linens may be stored in closets outside the laundry area.(G) The wall base of the laundry facilities must be continuous and coved with the floor, tightly sealed to the wall and constructed without voids that may harbor insects or moisture. This Rule is not met as evidenced by:

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to ensure resident’s rights of privacy in his or her own unit for 1 of 1 sampled resident (#4) whose door was propped open. Findings include, but are not limited to: Resident 4 was admitted to the facility in 05/2023 with diagnoses including essential hypertension, urinary incontinence, syncope and collapse, degenerative disease of nervous system, and right knee pain. The resident’s record was reviewed, interviews were conducted, and observations were made. The following was identified: * From 10/21/24 through 10/23/24, Resident 4’s door to his/her unit was observed propped fully open; * On 10/23/24 at 8:54 am, Staff 8 (Care Associate) stated Resident 4’s door was propped open for staff convenience; * On 10/23/24 at 9:39 am, Resident 4 was observed from the hallway in his/her unit, sitting in a recliner without pants on or a left shoe; * On 10/23/24 at 9:40 am, Staff 6 (Care Associate/MT) was observed to look in Resident 4’s unit while walking by, but stopped and entered the resident’s unit and stated “are you wet” and promptly after stated “yes, you are wet, let me help you…”; and * On 10/23/24 at 11:34 am, Staff 4 (Resident Service Director) stated the resident’s door was propped open for staff to keep an eye on him/her. The need to ensure residents' rights of privacy in his or her own unit was discussed on 10/23/24 at 12:58 pm, with Staff 1 (ED). She acknowledged the findings.

1. A conversation was completed with resident #4 asking if they prefer their door open or shut. 2. A TSP has been completed that resident prefers to have their door open at anytime the resident states otherwise the door is to be closed. 3. At every 90 day care assessment confirm the residents preferance on the door and as needed. 4. RSD and AWD.

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by: