Print Inspection: RL001315

OAR 411-054-0025 (9) Facility Administration: Quality Improvement (9) QUALITY IMPROVEMENT PROGRAM. The facility must develop and conduct an ongoing quality improvement program that evaluates services, resident outcomes, and resident satisfaction. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, resident outcomes, and resident satisfaction. Findings include, but are not limited to: During the survey, conducted 07/21/25 through 07/25/25, quality improvement oversight to ensure adequate resident care, services, and satisfaction was found to be ineffective. In an interview at 9:25 am on 07/25/25, Staff 1 (Executive Director) stated there was no documentation of the facility conducting a specific ongoing quality improvement program. The need to ensure the facility developed and conducted ongoing quality improvement programs was reviewed with Staff 1, Staff 2 (Assistant Executive Director), and Staff 3 (RN) on 07/25/25 at 9:30 am. They acknowledged the findings.

1. Quality improvement meeting is scheduled monthly. 2. All quality improvement meeting minutes will be stored in a QI binder. At each meeting the previous meeting minutes will be reviewed and any follow up actions identified. The QI meeting will address, at a minimum, resident outcomes, resident satisfaction, and an evaluation of resident services. 3. At least monthly and as needed depending on the QI project identified and implemented. 4. Executive Director or designee.

OAR 411-054-0025 (9) Facility Administration: Quality Improvement (9) QUALITY IMPROVEMENT PROGRAM. The facility must develop and conduct an ongoing quality improvement program that evaluates services, resident outcomes, and resident satisfaction. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, resident outcomes, and resident satisfaction. This is a repeat citation. Findings include, but are not limited to: During the survey, conducted 01/20/26 through 01/22/26, quality improvement oversight to ensure adequate resident care, services, and satisfaction was found to be ineffective. Multiple interviews conducted on 01/21/26 and 01/22/26 with residents residing in the MCC and RCF indicated that when complaints and grievances were raised, residents were told staff would “get right on it”; however, residents reported that the issues they raised were not resolved and did not result in any changes to care or services. In an interview at 9:35 am on 01/22/26, Staff 1 (Executive Director) stated there was no documentation of the facility conducting a specific ongoing quality improvement program. The need to ensure the facility developed and conducted ongoing quality improvement programs was reviewed with Staff 1 and Staff 2 (Assistant Executive Director) on 01/22/26 at 9:35 am. They acknowledged the findings. Refer to deficiencies in the report.

1. Quality improvement meeting is scheduled monthly. 2. All quality improvement meeting minutes will be stored in a QI binder. At each meeting the previous meeting minutes will be reviewed and any follow up actions identified. The QI meeting will address, at a minimum, resident outcomes, resident satisfaction, and an evaluation of resident services. 3. At least monthly and as needed depending on the QI project identified and implemented. 4. Executive Director or designee.

OAR 411-054-0025 (9) Facility Administration: Quality Improvement (9) QUALITY IMPROVEMENT PROGRAM. The facility must develop and conduct an ongoing quality improvement program that evaluates services, resident outcomes, and resident satisfaction. This Rule is not met as evidenced by:

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents, related to residents who required a secured memory care environment. Findings include, but are not limited to: The facility was an endorsed memory care community (MCC), which is defined as “a special care unit in a designated, separated area for residents with Alzheimer's disease or other forms of dementia that is locked or secured to prevent or limit access by a resident outside the designated or separated area.” During the acuity interview on 07/21/25, Staff 1 (Executive Director), Staff 3 (RN), and Staff 26 (RCC) identified 36 residents as residing in the MCC. Of the 36 residents, four were identified as having a history or risk of elopement and/or wandering the facility exit seeking. Throughout the survey, dated 07/21/25 through 07/25/25, the survey team observed Resident 8 approaching and attempting to open locked doors and windows throughout the MCC as s/he sought exit. a. The survey team identified two resident rooms which had sliding patio doors which opened easily and led to an unsecured outdoor area which included a hill, water feature, and accessed a large field. Both resident rooms were occupied. The doors did not have an alarm or other system to notify staff if a resident exited the facility into the unsecured area. During an interview at 8:30 am on 07/22/25, Staff 18 (MT) stated she was aware of the door in room 20 and had observed one of the room’s residents outside in the unsecured area “at times.” She stated that the unsecured courtyard was not considered a resident area. She stated other doors leading from resident areas, such as the dining room and living room, had keypad codes preventing residents from exiting into the unsecured courtyard without staff assistance. Staff 2 (Assistant Executive Director) stated at 8:35 am on 07/22/25 that she was aware that rooms 20 and 22 had patio doors which exited into an unsecured area. She confirmed that the outdoor area was not considered part of the secured MCC. She stated that she would address the safety concern “right now” with Staff 25 (Maintenance Director). At 3:50 pm on 07/22/25, the survey team identified that the patio doors continued to open, unimpeded, to the unsecured outdoor area. At 4:00 pm on 07/22/25, Staff 2 confirmed that no measures had been taken to prevent resident access to the unsecured area, but that she would address it immediately. At 4:19 pm on 07/22/25, the survey team confirmed that the patio doors had a physical limiter installed which prevented residents from accessing the unsecured area. b. On 07/24/25, the survey team identified windows in nine MCC resident rooms which opened fully and were at a height which could reasonably allow residents to access outdoor areas which were unsecured, including a parking lot, hill and field. Two windows in the MCC dining area opened fully and allowed for access to an unsecured outdoor area. In an interview on 07/24/25 at 3:30 pm, Staff 1 confirmed that the windows did not have a system to ensure residents in the MCC remained in the secured environment. She stated the facility had to remove limiters on the windows in the past, prior to her working at the facility, due to instruction from the local Fire Marshal’s office. She stated the facility had no documentation of this instruction. During interviews between 4:00 pm and 4:03 pm on 07/24/25, multiple facility staff stated that an unsampled resident who currently resided in the MCC who had previously exited the facility by climbing out his/her window, and the staff expected that s/he would attempt this again in the future. The facility staff identified 5 other residents who had a history or risk of elopement. On 07/24/25 at 5:39 pm, after discussions via phone with the CBC survey team and CBC management, the facility’s Oregon Policy Analyst, and Witness 1 (Division Chief - Fire Marshal, Central Douglas Fire & Rescue), the facility instituted a policy of documenting that each resident was visibly identified every 30 minutes to ensure all residents were accounted for inside the secured MCC. The need to ensure reasonable precautions were exercised against any condition that could threaten the health, safety or welfare of residents was reviewed with Staff 1, Staff 2 and Staff 3 (RN) on 07/25/25 at 9:30 am. They acknowledged the findings.

1. Room 20 & 22 patio doors are secured. All windows, including the 9 identified during survey are secured with fire marshal approval. The fence was erected to secure the resident's outdoor space. Fence has been raised 4 inches to meet code. Fire Marshal sent letter of approval for files. 2. All patio doors and windows are secured, all exits have alarms and key pads, and the fence is installed. 3. Walk-throughs both exterior and interior will be done at least daily by the managager on duty. 4. Executive director or designee, maintenance.

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

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure incidents of abuse or suspected abuse were immediately investigated to rule out abuse or neglect and/or reported to the local SPD office and to ensure injuries of unknown cause were reported to the local SPD unless an immediate facility investigation reasonably determined the injury was not the result of abuse for 3 of 5 sampled residents (#s 3, 4, and 5) whose records were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 09/2022 with diagnoses including dementia and was identified in the acuity interview as needing assistance with ADLs, as well as a history of falls with fall interventions in place. The resident’s 08/14/24 to 11/18/24 progress notes and incident reports were reviewed, and the following was identified: * An 08/14/24 incident report indicated the resident experienced an unwitnessed injury fall; * A 10/10/24 progress note documented, “some how [sic] on [his/her] left arm had 2 small skin tear[s]”; and * A 10/28/24 progress note documented, “[Resident 3] was walking in the dinning [sic] room and then [s/he] fell hitting [his/her] right side of ear and side of face on the right…[t]he skin tear was inside of [his/her] ear 3 cm in length.” There was no documented evidence the facility completed an immediate investigation that ruled out abuse or neglect for the above incidents. During an interview at 11:10 am on 11/20/24, Staff 1 (ED) confirmed the above incidents lacked an investigation and had not been reported to APS. The survey team requested the above incidents be reported to the local SPD office, and confirmation was received at 3:25 pm on 11/21/24. 2. Resident 4 was admitted to the facility in 04/2023 with diagnoses including dementia. The resident’s 08/15/24 to 11/18/24 progress notes and incident reports were reviewed, and the following was identified: * A 09/15/24 progress note documented, “resident having aggressive behavior [sic] punching grabbing and pushing resident[s]”; * A 09/19/24 progress note documented, “…[r]esident was walking down the hallway when another resident walked up to [him/her] and punched [him/her] in the face multiple times.”; * A 10/04/24 progress note documented, “…as [Resident 4] was walking by another resident attacked [him/her] …resident yelled out for help due to the other resident smashing [his/her] fingers….resident….is very afraid of being attacked again.”; * A 10/12/24 progress note documented, “[Unsampled resident] was involved in a Resident to Resident [sic] verbal threatening event…[Unsampled resident] was threatening to punch [Resident 4]…[Unsampled resident] balled up [his/her] fist and started to go forward”; and * A 10/16/24 progress note documented, “Resident was playing the piano…when [Unsampled resident] started yelling at [him/her] to [stop]…[Unsampled resident] headed toward [Resident 4], threatening [him/her]…they were both swinging and cursing at each other.” At the time of survey entrance on 11/18/24, Resident 4 and the unsampled resident in the above altercations had been separated, and there were no further altercations documented or reported between the two. There was no documented evidence the above incidents were reported to the local SPD office, and there was no documented evidence the unwitnessed injury fall had been investigated to rule out abuse or neglect or reported to the local SPD office if abuse could not be ruled out. During an interview at 11:10 am on 11/20/24, Staff 1 (ED) confirmed the above incidents lacked an investigation and/or had not been reported to APS. The survey team requested the above incidents be reported to the local SPD office, and confirmation was received at 3:25 pm on 11/21/24. The need to ensure incidents of abuse or suspected abuse were immediately reported to the local SPD office, and injuries of unknown cause were reported to the local SPD office unless an immediate investigation reasonably concluded the injuries were not a result of abuse or neglect was discussed with Staff 1 and Staff 2 (Assistant ED) on 11/21/24. She acknowledged the findings. 3. Resident 5 was admitted to the facility in 09/2022 with diagnoses including dementia and neuropathy. During the acuity interview on 11/18/24 Resident 5 was identified to require assistance with all ADL’s, as a high fall risk and having had recent falls. The resident’s 08/17/24 to 11/17/24 progress notes and incident reports were reviewed, and the following was identified: * An 08/17/24 incident report indicated the resident was involved in a resident-to-resident altercation; * A 08/20/24 incident report stated the resident was found “on the floor”; and * A 09/18/24 incident report stated the resident was “found on the floor by [his/her] bed.” There was no documented evidence the facility completed an immediate investigation that ruled out abuse or neglect for the above incidents. During an interview at 11:10 am on 11/20/24, Staff 1 (ED) confirmed the above incidents lacked an investigation. Staff 1 stated the facility had reported the incidents above to the local SPD office; however, she could not provide documented evidence they had been reported. The survey team requested the above incidents be reported to the local SPD office and confirmation was received after survey exit. The need to ensure the facility promptly investigated all reports of abuse and suspected abuse and reported to the local SPD office when necessary was discussed with Staff 1 and Staff 2 (Assistant ED) on 11/21/24 at 2:30 pm. They acknowledged the findings.

For Resident's 3,4,and 5; all requested incidents were faxed to APS. All incident reports will be filled out by Med-techs. If witnessed by a care partner or another staff member, a witness report will be completed and turned into the RN. The RN will do the investigation and determine if it needs to be reported. The RN or LPN will do a TSP according to the incident. Incident reports will be turned in the ED to file appropriately. If it is determined that the incident needs to be reported, a DHS form will be complated, sent, then filed. Fax confirmation will be attached. The incident reports will be brought to the clinical stand-up weekly on Monday. Executive director or designee.

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 notify the local Senior and People with Disabilities (SPD) office when an incident of abuse, or suspected abuse, occurred and failed to complete investigations with all required components for 1 of 1 sampled resident (#8). This is a repeat citation. Findings include, but are not limited to: Resident 8 was admitted to the facility in 06/2024 with diagnoses including dementia and atrial fibrillation (irregular heart rhythm). The resident's 05/01/25 through 07/20/25 progress notes, temporary service plans, incident reports, and incident investigations were reviewed, and interviews with staff were conducted. The following was identified: a. On 05/08/25, a progress note stated Resident 8 “was being aggressive towards care staff. [Resident] ended up with 3 skin tears.” An incident report dated 05/08/25 stated “4 care staff had to help get [him/her] dressed and was fight[ing] them. Ended up with 3 skin tears.” There was no documentation describing the event, such as how the skin tears occurred, staff involvement in the skin tears occurring, or the location of the skin tears. There was no documented evidence that the abuse or suspected abuse was immediately reported to the local SPD office. There was no documented evidence that an investigation occurred which included a description of the event, witness names, and administrator review. b. On 05/09/25 an incident report stated Resident 8 had a “skin tear on right forearm from resisting on [sic] being redirect[ed] to a different area.” The incident report stated, “[Resident] was agitated care staff was trying to redirect residen[t] and got aggressive and ended up with a skin tear on right forearm.” There was no documented description of how the skin tear occurred or staff involvement in the skin tear occurring. There was no documented evidence the abuse or suspected abuse was immediately reported to the local SPD office. There was no documented evidence an investigation occurred which included a description of the event and administrator review. c. On 05/12/25 an incident report stated, “[Resident] was trying to take [his/her] bandage off and started to be [aggressive]. Reopened [his/her] skin tears and a new one occurred.” The incident report re-stated “[Resident] reopened [his/her] skin tears and a new one occurred in the process.” There was no documentation regarding how the new skin tear occurred, the location of the new skin tear, or staff involvement in the skin tear occurring. There was no documented evidence the abuse or suspected abuse was immediately reported to the local SPD office. There was no documented evidence an investigation occurred which included a description of the event and administrator review. d. On 05/14/25 an incident report stated, “[Resident] has another skin tear on right forearm” and “Care staff was in a [resident’s] room [Resident 8] came in and started to get aggressive towards staff.” There was no description of how the skin tear occurred or staff involvement in the skin tear occurring. There was no documented evidence the abuse or suspected abuse was immediately reported to the local SPD office. There was no documented evidence an investigation occurred which included a description of the event, witness names, and administrator review. e. On 06/30/25, a progress note stated Resident 8 was demonstrating agitation, including yelling and grabbing at care staff. Resident 8 “walked up and was attempting to pull the other resident out of the recliner.” Resident 8 eventually let go of the other resident and was redirected, though continued to yell at staff. There was no documented evidence that the abuse or suspected abuse was immediately reported to the local SPD office. There was no documented evidence that an investigation occurred which included a description of the event, witness names, and administrator review. At the survey team’s request, all above incidents were reported by the facility to the local SPD office by 12:00 pm on 07/25/25. The need to ensure all incidents of abuse, or suspected abuse, were immediately reported to the local SPD office, and that investigations included all required components, was reviewed with Staff 1 (Executive Director), Staff 2 (Assistant Executive Director), and Staff 3 (RN) on 07/25/25 at 9:30 am. They acknowledged the findings.

1. All incidents identified during survey were reported to SPD on 7/25/25. 2. Incident reports are being reviewed daily during a clinical meeting. Any incident where abuse and neglect cannot be reasonably ruled out, including injuries of unknown cause, will be reported to the local SPD office within 24 hours. 3. Daily, weekly, monthly. 4. Executive director or designee, nursing.

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

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs; This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide an activity program based on individual and group interests, physical, mental, and psychosocial needs, and opportunities for active participation in the community at large. Findings include, but are not limited to: Observations conducted on 01/21/26 and 01/22/26 revealed a January activities calendar was posted in the MCC; however, no activities calendar was posted in the RCF. Review of the MCC activities calendar showed the following: Trivia was scheduled daily at 11:30 am; and Bingo was scheduled daily at 3:00 pm. On nine of the 31 days in January, there were only two activities listed: Trivia at 11:30 am and Bingo at 3:00 pm. On the remaining days, a third activity was listed, which consisted of one of the following: cooking club, book club, bible study, mail call, or movie and popcorn. No activities were scheduled or listed after 3:00 pm on any day. In interviews completed on 01/21/26 and 01/22/26, unsampled residents in the RCF confirmed there was no activities calendar available or posted. When asked what activities were offered that day, one resident pointed to a single piece of paper taped to the wall that stated, “Bingo at 3:00 pm.” When asked if any additional activities were offered, the resident stated “no” and reported spending the day sitting and waiting. Interviews completed on 01/21/26 and 01/22/26 with unsampled residents in the MCC revealed the residents spent the majority of the day sitting, watching television, or waiting for scheduled smoke breaks. One resident stated the scheduled activities, including bingo, did not align with his/her interests and described the activities as juvenile. Two residents stated they wanted to move to another facility in town due to the availability of more activities and outings and reported there was “nothing to do” at the current facility. In an interview on 01/21/26 at approximately 2:50, Staff 34 (Activities Director/Receptionist) stated activity evaluations had not been completed for most residents and acknowledged the overall activities program needed improvement. She stated there were designated activity staff scheduled Wednesday through Sunday but said care staff were responsible for orchestrating activities on the other two days. On 01/22/26 at 1:00 pm, the need to ensure an activities program based on individual and group interests, and which was person-centered and available during residents’ waking hours, was discussed with Staff 1 (Executive Director) and Staff 2 (Assistant Executive Director). They acknowledged the findings.

1. New full time activity director and 3 activity assistants were hired. There are separate activity calendars for memory care and RCF and both will include individual and group activies that will focus on physical, mental, and psychosocial needs based on resident preferences and abilities. 2. Full time activity director will work with activity assistants to implement new program with additional help from direct care staff. An activity tracking plan to be implemented. Executive director reviews with activity director the daily agenda. 3. Daily, weekly, monthly. 4. Executive director or designee, activity director.

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

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the move-in evaluation contained all required elements and addressed sufficient information to develop an initial service plan to meet the resident’s needs for 1 of 1 sampled resident (#6) who was recently admitted to the facility. Findings include, but are not limited to: Resident 6 moved into the facility in 09/2024 with diagnoses including dementia. The initial evaluation was reviewed and failed to address the following required elements: * Physical health status including list of current diagnoses, list of medications and PRN use, visits to health practitioner(s), emergency room, hospital or nursing facility in the past year and vital signs if indicated by diagnosis, health problems or medications; * Cognition, including memory, orientation, confusion and decision-making abilities; * List of treatments, type, frequency and level of assistance needed; * Indicators of nursing needs including potential for delegated nursing tasks; * Emergency evaluation ability; * Complex medication regimen; * Fall Risk or history; * Emergency evacuation ability; * Complex medication regimen; * History of dehydration or unexplained weight loss or gain; * Recent losses; * Unsuccessful prior placements; * Elopement risk or history; * Smoking, ability to smoke safely; * Alcohol and drug use; and * Environmental factors that impact the resident’s behavior including, but not limited to: noise, lighting and room temperature. Staff 7 (Marketing Director) on 11/21/24 at 8:40 am acknowledged the information was incomplete and stated there was difficulty obtaining information from Resident 6 at the time of the evaluation. The need to ensure the move-in evaluation included all required elements was discussed with Staff 7 on 11/21/24 at 8:40 am, and Staff 1 (ED) and Staff 2 (Assistant ED) on 11/21/24 at 2:30 pm. The findings were acknowledged.

Resident evaluation has been updated to reflect required information related to the new-move in. Marketing Director and RCC will ensure the resident evaluation has been completed prior to move in. Assistant ED and ED will review the new admission for the needed evaluations prior to move in. The ED or designee

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure initial evaluations addressed all required elements for 1 of 1 sampled resident (#7) whose move-in evaluation was reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 7 moved into the MCC in 05/2025 with diagnoses including dementia and diabetes mellitus. The initial evaluation, dated 04/14/25, was reviewed, and it failed to address the following elements: Preferences in bathing; Visits to health practitioners or Emergency Department in the past year; Cognition, including decision making abilities; Non-pharmaceutical interventions for pain; Indicators of nursing needs including potential for delegated nursing tasks; Complex medication regimen; Gender identity; Mental health issues; and Unsuccessful prior placements. The need to ensure the move-in evaluation included all required elements was reviewed with Staff 1 (Executive Director), Staff 2 (Assistant Executive Director), and Staff 3 (RN) on 07/25/25 at 11:00 am. They acknowledged the findings.

1. Surveyed resident 7 evaluation has been completed with all required elements. 2. All move-in evaluations will have a second review to ensure all required information is present. 3. Weekly, monthly, quarterly 4. Executive director or designee, Assistance director or designee.

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by:

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear direction to staff regarding the delivery of services for 4 of 5 sampled residents (#s 1, 2, 3, and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 11/2022 with diagnoses including type 2 diabetes mellitus and chronic kidney disease. Observation of the resident’s ADL care on 11/19/24, interviews with the resident and facility staff were conducted. The current service plan dated 11/12/24 was reviewed. Resident 1's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Incorrect reference to resident diet texture and liquid consistency; * Incorrect reference to required presence of staff member during meals; * Instructions to staff on providing care to the resident with right-sided weakness secondary to a history of three strokes; * Instructions to staff on providing care to the resident with mild aphasia; * Instructions to staff on blood glucose monitoring protocol when resident slept late and skipped breakfast; * Instructions on signs and symptoms of hypoglycemia and hyperglycemia to report; * Instructions on signs and symptoms of depression to report while on anti-depressant therapy; * Presence of depression, thought disorders, behavioral and mood problems; * Personality, including how the person coped with change or challenging situations; * Non-pharmaceutical interventions for pain, including how a person expresses pain or discomfort; * How a person expressed memory loss; * Number of staff needed to assist with emergency evacuations; * Instructions on fall prevention; * Skin integrity and instructions on to whom to report skin impairments; and * Incontinence care and maintenance of supplies. The need to ensure the service plan reflected the resident’s current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (ED) and Staff 2 (Assistant ED) on 11/21/24 at 3:00 pm. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 11/2022 with diagnoses including hypertension, depression, and chronic obstructive pulmonary disease (COPD). Interviews with the resident and facility staff were conducted. The current service plan dated 09/24/24 was reviewed. Resident 2's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Instructions on signs and symptoms of depression to report while on anti-depressant therapy; * Incorrect reference to resident administration of medications; * Instructions on what types of skin impairments to report and to whom; * Instructions for signs and symptoms of infection to report while monitoring incision site with staples; and * Incorrect reference to resident being a smoker. The need to ensure the service plan reflected the resident’s current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (ED) and Staff 2 (Assistant ED) on 11/21/24 at 3:00 pm. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 09/2022 with diagnoses including dementia. The resident’s service plan dated 10/02/24 and temporary service plans dated 08/14/24 to 11/18/24 were reviewed. Observations of the resident were made, and interviews with staff were conducted. The resident’s service plan was not reflective of current needs in the following areas: * Eating assistance; * Diet texture; * Mobility and transfer assistance; * Fall history; * Dentition status; and * Weight loss history. The need to ensure service plans were reflective of the resident’s current needs was discussed with Staff 1 (ED) and Staff 2 (Assistant ED) on 11/21/24. She acknowledged the findings. 4. Resident 5 was admitted to the facility in 09/2022 with diagnoses including dementia and neuropathy. The service plan dated 10/09/24, temporary service plans, and progress notes dated 08/17/24 through 11/17/24 were reviewed. Interviews with care staff were conducted, and observations of the resident were made. The resident's service plan was not reflective or failed to provide clear instruction to staff in the following areas: * Medications regarding refusals; * Fall risk and interventions; * Emergency evacuation; * Hearing aids; * Toileting; and * Mobility/transfers. The need to ensure service plans were reflective of the resident's care needs and provided clear instruction to staff was discussed with Staff 1 (ED) and Staff 2 (Assistant ED) on 11/21/24 at 2:30 pm. They acknowledged the findings.

Resident service plan will be completed by talking to the resident, family members, case workers and friends, if available. The resident evaluation and life story will be used to complete the service plan. A care conference schedule will be completed in the prior month, and handed out to all entities involved to ensure they have their information required available and completed. The correction will be reviewed monthly. Executive Director or designee.

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents’ needs and preferences; were readily available to staff; provided clear direction regarding the delivery of services, which included a written description of who should provide the services and what, when, how, and how often the services should be provided; and changes and entries made to the service plan were dated and initialed for 3 of 3 sampled residents (#s 7, 8, and 9). This is a repeat citation. Findings include, but are not limited to: 1. Resident 7 moved into the MCC in 05/2025 with diagnoses including dementia and diabetes mellitus. a. The resident's current service plan, dated 06/09/25, was not readily available to staff. The service plan available to staff was dated 05/06/25. b. Observations of the resident, interviews with the resident and staff, review of the resident's service plan, dated 05/06/25, and progress notes, dated 05/06/25 to 06/27/25, were completed. The resident’s service plan was not reflective of current needs and/or did not provide clear direction to staff in the following areas: Vision loss in the resident’s right eye; Ambulation status and when the resident should use his/her walker for mobility; Delegation of insulin and signs and symptoms of low and high blood sugars; Environmental factors that impacted the resident’s behavior; How staff were to assist the resident with smoking; and Non-pharmaceutical interventions for pain. c. There were handwritten updates that lacked staff initials and dates. The need to ensure service plans were reflective of residents’ needs and preferences, were readily available to staff, and provided clear direction regarding the delivery of services which included a written description of who should provide the services and what, when, how, and how often the services should be provided; and changes and entries made to the service plan were dated and initialed was reviewed with Staff 1 (Executive Director), Staff 2 (Assistant Executive Director), and Staff 3 (RN) on 07/25/25 at 11:00 am. They acknowledged the findings. 2. Resident 9 was admitted to the facility in 11/2022 with diagnoses including vascular dementia. The resident’s 06/18/25 service plan and 05/01/25 through 07/01/25 temporary service plans were reviewed, and staff were interviewed. The service plan was not reflective of the resident’s status and care needs in the following areas: * Use of a fall mat; * Frequency of safety checks; * Repositioning every two hours; * Two-person transfer; * Dental status; * Pain medications; and * Need of meal assistance. The need for service plans to be reflective of the resident’s current status and care needs was discussed with Staff 1 (Executive Director) and Staff 2 (Assistant Executive Director) on 07/24/25 at 9:55 am. They acknowledged the findings. 3. Resident 8 was admitted to the facility in 06/2024 with diagnoses including dementia and atrial fibrillation (irregular heart rhythm). The resident’s 06/11/25 service plan, 05/01/25 through 07/01/25 temporary service plans, and 6/30/25 behavioral support plan were reviewed, and staff were interviewed. The service plan was not reflective of the resident’s status and/or did not provide clear direction regarding the delivery of services, including a written description of who should provide the services and what, when, how, and how often the services should be provided, in the following areas: * Incontinence care, including how staff should assist the resident when providing toileting assistance and the resident’s preferences for undergarments; * Frequency of safety checks; * Non-pharmacological interventions for pain; * Behavioral support plan interventions did not include clear directions for staff to implement and were not being implemented; * Interventions to decrease fall risk; and * Assistance with personal hygiene, including services staff assist with and frequency. The need for service plans to be reflective of the resident’s current status and provide clear direction regarding the delivery of services was reviewed with Staff 1 (Executive Director), Staff 2 (Assistant Executive Director), and Staff 3 (RN) on 07/25/25 at 9:30 am. They acknowledged the findings.

1. Service plans for surveyed residents 7, 8, & 9 were reviewed and updated to reflect current needs and clear direction to staff. Service plans are available to staff. 2. A system for tracking when service plans are due for review will be implemented. New or updated service plans will be available to staff in the alert book then moved to the service plan binder once staff have reviewed. 3. Weekly, monthly, quarterly 4. Executive director or designee, assistant executive director or designee.

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear direction to staff regarding the delivery of services for 3 of 4 sampled residents (#s 8, 11, and 12) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 8 was admitted to the facility in 06/2024 with diagnoses including dementia and atrial fibrillation (irregular heart rhythm). Observations of the resident, interviews with staff, and review of the resident's current service plan, dated 01/05/26, temporary service plans dated 12/01/25 through 01/21/26, and the behavioral support plan dated 06/30/25 were completed. The resident’s service plan was not reflective of the resident’s current needs and/or did not provide clear and specific direction to staff in the following area: Interviews with staff throughout the survey indicated that Resident 8 believed another unsampled resident was his/her spouse and repeatedly sought proximity to this resident. Resident 8 was observed on 01/21/26 and 01/22/26, between 10:30 am and 12:00 pm, standing in close proximity to the unsampled resident’s personal space. The unsampled resident was primarily non-verbal, increasing his/her vulnerability and the need for staff intervention. Review of the service plan further noted that Resident 8 became upset when other residents of a certain gender were talking or interacting with the unsampled resident. The service plan lacked clear and specific directions for staff on how to intervene, redirect, or manage Resident 8’s behaviors. It did not clearly describe when staff should intervene, what actions were appropriate, or how to support and maintain personal boundaries and respect for another resident’s personal space. The need for service plans to be reflective of the resident’s current needs and to provide clear directions to staff regarding appropriate interventions and supervision was discussed with Staff 1 (Executive Director), Staff 2 (Assistant Executive Director), and Staff 3 (RN) on 01/22/26 at 1:00 pm. They acknowledged the findings 2. Resident 11 was admitted to the facility in 10/2020 with diagnoses including dementia. Observations conducted on 01/21/26 and 01/22/26, interviews with care staff during survey, and review of the 12/01/25 through 01/20/26 progress notes, 12/18/25 service plan, temporary service plans, incident reports, and weight records revealed that the Resident 11 had sustained several significant changes of condition with increased confusion, multiple falls, a decline in ADLs, and significant weight loss. The resident was observed to require one person assist with bed mobility when moving from laying to sitting, transfers to and from bed, and with toileting, dressing, grooming, and hygiene. The resident was observed ambulating using a walker with one person contact guard assist. On 01/21/26 at 9:00 am, Staff 45 (CG) reported the resident was hard of hearing and staff needed to stand close to the ear and speak loudly for him/her to understand them. She stated that the resident used to be independent with transfers, ambulation, and toileting with no device and needed set-up assist for dressing, grooming, hygiene, and showers. Staff 45 reported that the resident now needed more help due to increased confusion and multiple falls. Review of the service plan and temporary service plans revealed the service plan was not reflective, and did not provide clear instruction for staff in the following areas: * Communication and instructions for staff to ensure resident could hear/understand; * Assistance with bed mobility, transfers, toileting, and ambulation using a walker; * Dressing, grooming, hygiene, and shower assistance; * History of significant weight loss with interventions; and * Fall history, interventions, and clear instructions for staff. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Executive Director), Staff 2 (Assistant Executive Director), and Staff 3 (RN) on 01/22/26 at 12:00 pm. They acknowledged the findings. 3. Resident 12 was admitted to the facility in 09/2019 with diagnoses including dementia, schizophrenia, traumatic brain injury, and anxiety disorder. Observations of Resident 12 during survey, interviews with staff, and review of the12/18/25 service plan, progress notes, and temporary service plans revealed the service plan was not reflective or did not provide clear direction in the following areas: * History of mental health treatment, including previous behavioral support plans; * Past interests, hobbies, and activity preferences; * Effective non-drug interventions for behaviors; * Techniques for communicating with the resident; and * Emotional and social needs of the resident. Observations of the resident, review of clinical records, and interviews with staff revealed Resident 12 was currently “bed-bound,” non-verbal, and required a Hoyer lift for all transfers, full assist with eating, and full care with all ADLs. On 01/22/26 at 11:50 am, the need to ensure service plans were reflective and provided clear instructions to staff was discussed with Staff 1 (Executive Director) and Staff 2 (Assistant Executive Director). They acknowledged the findings.

1. Service plans for surveyed residents 1, 8, and12 were reviewed and updated to reflect current needs and clear direction to staff. Service plans are available to staff. 2. A system for tracking when service plans are due for review will be implemented. New or updated service plans will be available to staff in the alert book then moved to the service plan binder once staff have reviewed. 3. Weekly, monthly, quarterly 4. Executive director or designee, RCC, assistant executive director or designee.

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

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed for a significant change of condition, and failed to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff, document progress until the condition resolved for 3 of 5 sampled residents (#s 1, 2, and 3) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 11/2022 with diagnoses including type 2 diabetes mellitus and chronic kidney disease. Clinical records, including the resident’s current service plan, dated 11/12/24, progress notes from 07/26/24 through 11/18/24, and outside provider notes, were reviewed, and interviews with the resident and facility staff were conducted. a. The following significant change of condition lacked documentation the facility evaluated the resident, referred timely to the facility nurse, documented the change, and updated the service plan as needed: * 09/25/24: food texture has been downgraded to minced and moist; drink thickness was upgraded to nectar thick. b. The following short-term changes 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/or documented weekly progress until the condition resolved: * 10/07/24: recorded oxygen saturation of 88% (below 92%); * 10/08/24: recorded blood sugar level 399 mg/dl (above 350 mg/dl); * 11/02/24: recorded blood sugar level 56 mg/dl (below 70 mg/dl); * 11/03/24: recorded blood sugar level 60 mg/dl (below 70 mg/dl); * 11/15/24: recorded oxygen saturation of 91% (below 92%); and * 11/16/24: “…blood sugar level of 427 at 1:30 pm, nurse was called and instructed me to send [him/her] out. Resident is refusing and does not want to go to the hospital.” The need to ensure the facility evaluated the resident, referred to the facility nurse, documented the change, and updated the service plan as needed for a significant change of condition, and 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) and Staff 2 (Assistant ED) on 11/21/24. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 11/2022 with diagnoses including hypertension, depression, and chronic obstructive pulmonary disease (COPD). Clinical records, including the resident’s current service plan, dated 09/24/24, progress notes from 08/19/24 through 11/18/24, and outside provider notes, were reviewed, and interviews with the resident and facility staff were conducted. a. The following significant change of condition lacked documentation the facility evaluated the resident, referred timely to the facility nurse, documented the change, and updated the service plan as needed: * 09/17/24: hospitalized due to fracture of the left femur secondary to a fall. b. The following short-term changes 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/or documented weekly progress until the condition resolved: * 09/20/24: discharged from the hospital following a surgery related to left femur fracture; * 10/01/24: “Resident shows day 8 no BM (bowel movement)”; * 11/04/24: discharged from the hospital following “hip revision due to misalignment from prior ORIF [Open Reduction Internal Fixation]. While there s/he developed sepsis from UTI [Urinary tract infection]….S/he is currently…unstable due to the surgical revision to the left hip.”; * 11/08/24: “Ciprofloxacin (antibiotic) arrived today…”; and * 11/13/24: “S/he no longer has hydrocodone (for pain control) or oxy [oxycodone] (for pain control)”. The need to ensure the facility evaluated the resident, referred to the facility nurse, documented the change, and updated the service plan as needed for a significant change of condition, and 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) and Staff 2 (Assistant ED) on 11/21/24 at 3:00 pm. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 09/2022 with diagnoses including dementia. The resident’s service plan dated 10/02/24, and progress notes, temporary service plans, and incident reports dated 08/14/24 to 11/18/24 were reviewed, and interviews with staff were conducted. The following was identified: a. There was no documented evidence resident-specific actions/interventions were determined, documented, and communicated to staff on each shift for the following changes of condition: * 10/28/24 – Injury fall; * 11/04/24 – Injury fall; and * 11/12/24 – Non-injury fall. During an interview at 9:26 am on 11/20/24, Staff 3 (RN) confirmed the above changes of condition did not have resident-specific actions or interventions determined, documented, and communicated to staff on each shift. b. There was no documented evidence the following changes of condition were monitored with weekly progress noted to resolution: * 08/18/24 – Skin tear right hand; * 10/10/24 – Two skin tears on left arm; * 10/18/24 – Redness on buttocks; * 10/28/24 – Right ear skin tear; * 11/04/24 – Injury fall; and * 11/04/24 – Skin tear right arm. During an interview at 9:14 am on 11/20/24, Staff 4 (LPN) confirmed the above changes of condition were not monitored at least weekly to resolution. The need to ensure resident-specific actions/interventions were determined, documented, and communicated to staff on each shift and weekly progress was noted to resolution for short-term changes of condition was discussed with Staff 1 (ED) and Staff 2 (Assistant ED). She acknowledged the findings, and no further information was provided.

Change of conditions were completed for Resident 1 and Resident 2 to address the deficiencies listed. An inservice will be held to review the policy on Change of Condition. The attendees will sign they have been informed of this policy. Any change of condition will be reviewed at the morning clinical stand-up Monday - Friday. The ED or designee will monitor the change of condition is completed weekly for 6 weeks then monthly for 3 months.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to determine and document what actions or interventions were needed for short-term changes of condition, communicate resident-specific instructions and interventions to staff on each shift, and monitor the change of condition, at least weekly, until resolved for 2 of 3 sampled residents (#s 8 and 9) who experienced short-term changes of condition. This is a repeat citation. Findings include, but are not limited to: 1. Resident 9 was admitted to the facility in 11/2022 with diagnoses including vascular dementia. The resident’s 06/18/25 service plan, 05/01/25 through 07/01/25 temporary service plans (TSPs), 04/23/25 through 07/18/25 progress notes, and incident reports were reviewed, and staff were interviewed. The resident experienced the following falls: * 05/10/25 – Unwitnessed, with no injury; * 05/31/25 – Unwitnessed, with no injury; and * 07/18/25 – Witnessed, with an injury. The resident was placed on alert charting after the 05/10/25 and 05/31/25 falls and monitored for signs of pain and discomfort. There was no documented evidence actions or interventions were determined, documented, communicated to staff on all shifts, implemented, or evaluated after the resident’s second fall on 05/31/25. After his/her third fall on 07/18/25, there was no documented evidence staff were instructed to monitor the resident and no documented interventions. The need for actions or interventions to be determined, documented, implemented, and evaluated for effectiveness was discussed with Staff 1 (Executive Director) and Staff 2 (Assistant Executive Director) on 07/24/25 at 9:55 am. They acknowledged the findings. 2. Resident 8 was admitted to the facility in 06/2024 with diagnoses including dementia and atrial fibrillation (irregular heart rhythm). The resident’s 06/11/25 service plan, 04/23/25 through 07/01/25 temporary service plans (TSPs), progress notes, and incident reports were reviewed, and staff were interviewed. The following was identified: a. On 04/23/25, a TSP stated that the resident’s left big toe had “split open.” There was no documented evidence that the wound was monitored at least weekly through resolution. b. On 05/01/25, the resident was moved to a new room in a different part of the MCC due to “wandering.” Staff were instructed via TSP to monitor the resident, though there was no evidence of communication of the signs or symptoms staff should be monitoring for or what to report and when. c. The resident was identified in his/her service plan as having had multiple falls which required hospital visits prior to the reviewed time period and was on blood thinning medication which increased potential risk of injury when falls occurred. The service plan did not include any specific instructions to staff to address his/her fall risk and reduce the risk of future falls. The resident was observed during the survey to ambulate independently, with a shuffling and unsteady gait pattern at times, through the community, with repeated wandering behaviors. On 05/02/25, the resident experienced a fall which resulted in him/her hitting the back of his/her head and required evaluation at the hospital. There was no documented evidence that the facility determined and documented what action or intervention was needed for the resident to reduce risk of future falls. The resident experienced another fall on 05/23/25 which reopened previous skin tears. There was no documented evidence that the facility determined and documented what action or intervention was needed for the resident to reduce risk of future falls. d. The resident experienced repeated behaviors on 05/08/25, 05/09/25, 05/12/25, and 05/14/25 including aggression toward staff, refusal of ADL care, and picking at his/her bandaged forearms. There was no documented evidence that the facility determined and documented what action or intervention was needed for the resident in order to address his/her behaviors. e. The resident experienced skin tears on his/her forearms on 05/08/25, 05/09/25, 05/12/25, and 05/14/25. There was no documented evidence that the skin tears were monitored at least weekly through resolution. f. The resident had incorrect doses of warfarin (blood thinner) administered on 06/07/25, 06/15/25, 06/16/25, 06/21/25, 06/22/25, 06/23/25, 06/27/25, and 06/28/25. There was no documented evidence that the resident was monitored for potential adverse side effects at least weekly through resolution. The need for actions or interventions to be determined, documented, communicated to staff on all shifts, and monitored at least weekly through resolution was reviewed with Staff 1 (Executive Director), Staff 2 (Assistant Executive Director), and Staff 3 (RN) on 07/25/25 at 9:30 am. They acknowledged the findings.

1. TSPs with appropriate interventions and monitoring instructions for surveyed residents 8 & 9 were implemented. Alert monitoring and nursing assessments completed for any follow up needed related to injuries, behaviors, ADL changes, and incorrect warfarin administration. 2. A clinical meeting is done Monday-Friday to include TSP review, chart notes, incident reports, and medication changes. 3. Daily, weekly, monthly 4. Executive director or designee, nursing.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed for short-term changes of condition, communicate resident-specific instructions and interventions to staff on each shift, and monitor the change of condition, at least weekly, until resolved for 2 of 3 sampled residents (#s 11 and 13) who experienced short-term changes of condition. This is a repeat citation. Findings include, but are not limited to: 1. Resident 13 was admitted to the facility in 06/2024 with diagnoses including dementia and arthritis. The resident’s clinical record was reviewed and identified the following: * Progress notes dated 12/01/25 indicated the resident was added to alert charting due to a recent non-injury fall out of bed. Interventions were determined and communicated to staff; however, there was no documentation the fall out of bed was monitored until resolution; * Progress notes dated 12/19/25 indicated the resident was involved in a resident-to-resident altercation. Interventions were documented and communicated to staff; however, there was no documentation that the resident-to-resident altercation was monitored until resolution; * Progress notes dated 01/01/26 indicated the resident was involved in a resident-to-resident altercation and had been pulled out of his/her chair onto the floor. A temporary service plan dated 01/01/26 stated, “recent fall no injuries” and “resident to resident altercation fell out of wheelchair." There was no documentation the facility had determined and documented resident-specific actions or interventions related to the resident-to-resident altercation, nor was there documentation that the incident was monitored until resolution; and * Progress notes dated 01/05/26 indicated the resident was placed on alert charting due to a change in behavior, with documentation stating: “[Resident 13] has become more angry than normal, and is refusing to be changed more often, and has been getting into altercations with other residents.” There was no documentation that the facility had determined and documented what actions or interventions were needed, communicated resident-specific instructions or interventions to staff on each shift, or monitored the change of condition, with progress noted at least weekly until resolution. The service plan dated 11/21/25 stated the resident “will yell at staff and other residents, along with taunting other residents causing other residents to react. . . . Staff are to redirect the resident and speak to the resident in a calm manner.” The service plan further noted “if behaviors are present, remove the resident from the situation and talk with [Resident 13] one to one. . . . Staff may remind [Resident 13] that a smoke break is upcoming.” On 01/21/26 at 12:20 pm, Staff 14 (CG) reported that when the resident’s behavior became escalated, staff attempted to redirect him/her to another area. The need to ensure interventions for changes of condition were communicated to staff on all shifts and were monitored weekly through resolution was discussed with Staff 1 (Executive Director), Staff 2 (Assistant Executive Director), and Staff 3 (RN) on 01/22/26 at 1:00 pm. They acknowledged the findings. 2. Resident 11 was admitted to the facility in 10/2020 with diagnoses including dementia. The resident’s clinical record was reviewed and revealed the following: The resident experienced the following falls: * 12/02/25 – Unwitnessed, with no injury. An intervention to check on the resident frequently was determined but was not communicated to staff on all shifts; * 12/03/25 – Unwitnessed, with head strike. An intervention to ensure the resident wore non-skid socks when in bed was determined but was not communicated to staff on all shifts; * 12/06/25 – Unwitnessed, with no injury. An intervention was determined to provide assist when getting up from bed or chair but was not communicated to staff on all shifts; *12/31/25 – Unwitnessed, with no injury. The intervention to check on resident frequently was determined but was not communicated to staff on all shifts; and *01/03/26 – Unwitnessed, with possible head injury. An intervention was determined for the resident to use the walker at all times, but was not communicated to staff on all shifts, and there was no documented monitoring of progress through resolution. Resident 11 was observed on 01/21/26 at 11:15 am getting up from bed without non-skid socks on his/her feet and was observed ambulating from the dining room to the community bathroom without use of a walker or staff assistance. During an interview on 01/2/26 at 9:00 am, Staff 45 (CG) reported she was unaware the resident needed to have non-slip socks on in bed. The need to ensure interventions for changes of condition were communicated to staff on all shifts, and were monitored weekly through resolution, was discussed with Staff 3 (RN) and Staff 4 (LPN) on 01/21/26 at approximately 2:00 pm, and with Staff 1 (Executive Director), Staff 2 (Assistant Executive Director), and Staff 3 on 01/22/26 at 12:00 pm. They acknowledged the findings.

1. Surveyed resident 11 & 13 resolution assessment and documentation completed. All TSPs and service plans updated with fall interventions for both resident 11 & 13 and behavior interventions for resident 13, which is availabe to staff in the alert charting binder. 2. A clinical meeting is done Monday-Friday to include service plan review, chart notes, TSPs, incident reports, and medication changes. This will ensure monitoring will be reviewed through resolution with updated TSPs. 3. Daily, weekly, monthly 4. Executive director or designee, nursing.

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 observation, interview, and record review, it was determined the facility failed to ensure an RN assessed a significant change of condition for 1 of 1 sampled resident (#9) who experienced significant weight loss. Findings include, but are not limited to: Resident 9 was admitted to the facility in 11/2022 with diagnoses including vascular dementia. During the acuity interview on 07/21/25, Resident 9 was identified as being on hospice. The resident’s 06/18/25 service plan, 04/23/25 through 07/18/25 progress notes, 05/01/25 through 07/01/25 temporary service plans (TSPs), and 01/01/25 through 07/15/25 weight records were reviewed. Observations were made, and staff were interviewed. Weight records indicated the following: * 03/01/25: 107.2 pounds; * 04/01/25: 75 pounds; * 05/01/25: 107.8 pounds; * 06/01/25: 107.8 pounds: * 07/01/25: 101.8 pounds; and * 07/15/25: 102.2 pounds. A quarterly nursing assessment completed on 04/03/25 indicated the 75 pound weight on 04/01/25 was incorrect and was actually 110 pounds. Between 06/01/25 and 07/01/25 the resident lost 6 pounds, or 5.56% of his/her total body weight. This constituted a significant change of condition, for which an RN assessment should have been completed. Observations of Resident 9 during the lunch meal on 07/22/25 and 07/23/25 showed staff sat with the resident and attempted to feed him/her when s/he did not feed himself/herself. The resident was resistant to being fed during both meals. On 07/22/25, the resident ate less than 25% of his/her lunch. On 07/23/25, s/he ate 50% of his/her lunch. A TSP dated 07/01/25 instructed staff to “Help and monitor [Resident 9] at all meal times [sic] [with] ensures [sic] to help [with his/her] weight loss.” Alert charting for this TSP was resolved on 07/18/25, with a progress note that stated, “Not eating all [his/her] food. Has a meal companion to help [him/her] eat better.” There was no documented evidence a significant change of condition assessment had been completed by the RN. On 07/23/25 at 10:01 am, when asked for a copy of the significant change of condition assessment for Resident 9’s weight loss, Staff 3 (RN) replied, “[Resident 9 is] on hospice. I don’t do significant changes [of condition assessments] for hospice. They do their own.” In an interview on 07/24/25 at 9:55 am, Staff 1 (Executive Director) confirmed the RN did not do significant change assessments for residents on hospice. The need for all significant changes of condition, including for residents on hospice, to be assessed by an RN was discussed with Staff 1 and Staff 2 (Assistant Executive Director) on 07/24/25 at 9:55 am. They acknowledged the findings.

1. The RN completed a significant change of condition assessment for surveyed resident 9 related to weight loss. 2. Resident weights are tracked and the RN will complete a significant change of condition assessment if a significant weight change occurs within 1 month, 3 months, or 6 months. Any significant change of conditions are discussed during the clinical meeting. 3. Daily, weekly, monthly. 4. Executive director or designee, nursing.

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)(f)(B) RN Delegation and Teaching (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:(B) Delegation and Teaching. Delegation and teaching must be provided and documented by a RN in accordance with the Oregon Administrative Rules adopted by the Oregon State Board of Nursing in chapter 851, division 047. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure delegation and teaching was provided and documented by a RN in accordance with the Oregon Administrative Rules (OAR) adopted by the Oregon State Board of Nursing (OSBN) in chapter 851, division 047 for 1 of 1 sampled resident (#1) who received insulin injections by a facility unregulated assistive person (UAP). Findings include, but are not limited to: Pursuant to OAR chapter 851 division 006, delegation process means the process utilized by an RN to authorize an UAP to perform a nursing procedure for a client, the outcome of which the RN retains accountability for. The RN must document all delegation process decisions, actions and outcomes pursuant OAR 851-045 including comprehensive assessment, reasoned conclusions that identify client problems and risks, educate the UAP and evaluate their learned knowledge, and provide a one-on-one education and evaluation experience with the UAP and the client. During the acuity interview on 11/18/24, Resident 1 was identified to be administered an insulin injection four times daily by a facility UAP. Resident 1's MARs from 10/01/24 through 11/18/24 revealed insulin injections had been given by Staff 10 (RCC), Staff 23 (MT), and two other UAPs who were no longer employed at the facility. On 11/20/24, the surveyor observed Staff 23 prepare and administer an insulin injection to Resident 1. Staff 2 (RN) assumed nursing oversight at the facility on 10/01/24. During the interview on 11/19/24 at 4:40 pm, Staff 2 stated the previous RN had terminated employment without transferring nursing delegation. The previous nursing delegation binders contained multiple forms without clear and appropriate delegation documentation. Upon starting employment, Staff 2 created a new nursing delegation binder, including comprehensive RN assessments for all residents who received insulin injections by facility UAP. During the interviews on 11/20/24 and 11/21/24, Staff 2 confirmed Staff 10 and Staff 23 were not delegated to prepare and administer insulin injections for Resident 1. Training and initial delegation for Staff 10 and Staff 23 were completed while the survey team was on site. Staff 2 verbalized understanding that the facility RN bore ultimate responsibility for all nursing tasks administered by UAPs in the facility. The need to ensure nursing delegation and teaching to facility UAPs was provided and documented by a RN in accordance with the Oregon Administrative Rules (OAR) adopted by the Oregon State Board of Nursing (OSBN) in chapter 851, division 047 was reviewed with Staff 1 (ED) and Staff 2 on 11/21/24 at 3:00 pm. They acknowledged the findings.

All delegations for Med-tech's have been completed. The new hire for Med-tech will shadow a trained Med-tech for 2 days, then observed passing medications by the trainer. The RN will do medication pass observation and if RN determines he/she is competent the Med-tech will work for at least 1 week to become elegible for delegated. As persons are hired the business office manager and the RCC will review training and report to the RN when the new hire has completed the training. ED or designee.

OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching (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:(B) Delegation and Teaching. Delegation and teaching must be provided and documented by a RN in accordance with the Oregon Administrative Rules adopted by the Oregon State Board of Nursing in chapter 851, division 047. This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled resident (#1) whose MARs and controlled substance disposition logs were reviewed for accuracy. Findings include, but are not limited to: Resident 1 was admitted to the facility in 11/2022 with diagnoses including type 2 diabetes mellitus and chronic kidney disease. Resident 1's MAR from 10/01/24 through 11/18/24, the facility’s controlled substance disposition logs, and the resident’s current physician orders were reviewed. Resident 1 had a physician order for oxycodone/acetaminophen [APAP] 5-325 mg, one tablet orally every six hours as needed for chronic pain. The following inaccuracies were identified between the resident's MAR and the controlled substance disposition log: a. The controlled substance disposition log recorded dispensing the following doses: * 10/12/24 at 1:20 am; * 10/13/24 at 7:00 pm; * 11/02/24 at 6:00 pm; and * 11/17/24 at 8:00 pm. There was no record the above doses had been administered in the resident’s MAR. b. According to the resident’s MAR, a dose was documented as administered on 10/08/24 at 9:21 am, but the controlled substance disposition log did not have a record of this administration. In an interview on 11/19/24 at 3:20 pm Staff 3 (RN) acknowledged the discrepancies. The need to ensure the facility had an effective system for tracking controlled substances was reviewed with Staff 1 (ED) and Staff 2 (Assistant ED) on 11/21/24 at 3:00 pm. They acknowledged the findings.

We are unable to go back and correct the past but in the future the medications signed out will also be signed in the MAR. The RCC will review the narcotic books and match the signed out narcotics to the MAR daily during the week. The LPN will review the books monthly. The Med-tech will be notified to come in the same day to remedy the problem. Managed Health Care Pharmacy comes in quarterly to audit the narcotic books, MARs and the system. RN or designee will audit for discrepancies weekly.

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

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure physician's orders were carried out as prescribed for 2 of 5 sampled residents (#s 1 and 5) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 09/2022 with diagnoses including dementia and neuropathy. Review of the MAR, dated 11/01/24 through 11/18/24, and current physician's orders, dated 10/29/24, noted Resident 5 was prescribed a “soft diet”. During the acuity interview on 11/18/24 at 11:45 am, Resident 5 was identified to have a pureed diet. Staff interviews and meal observations on 11/18/24 and 11/19/24 confirmed Resident 5 was provided a pureed diet. In an interview at 10:17 am on 11/19/24, Staff 3 (RN) confirmed the pureed diet was not the ordered diet. She further confirmed dietary staff had been updated with the correct diet order, and observations made of the resident during lunch at 11:55 am confirmed the diet order had been corrected. The need to ensure physician's orders were carried out as prescribed was discussed with Staff 1 (ED) and Staff 2 (Program Director) on 05/22/24. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 11/2022 with diagnoses including type 2 diabetes mellitus and chronic kidney disease. Review of Resident 1’s physician orders signed 09/25/24 and MAR from 10/01/24 through 11/18/24 noted the following: * Glargine Insulin 100 U/ml insulin was ordered for injection 40 units subcutaneously once daily in the morning to control blood glucose with instructions to hold if blood glucose level was less than 120. There was no documented evidence insulin was held based on these instructions on three occasions. The administration of the insulin had no negative outcome to Resident 1. * Resident 1 had a diet order for nectar thick liquid consistency. Based on the breakfast meal observed on 11/19/24 at 8:46 am, Resident 1 was given thin liquid consistency. Staff 3 (RN) was notified on 11/19/24, and the physician’s prescribed liquid consistency was implemented starting 11/19/24. There was no negative outcome to Resident 1. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (ED) and Staff 2 (Assistant ED) on 11/21/24 at 3:00 pm. They acknowledged the findings.

We are unable to go back and correct the past but in the future the medications signed out will also be signed in the MAR. The RCC will review the narcotic books and match the signed out narcotics to the MAR daily during the week. The LPN will review the books monthly. The Med-tech will be notified to come in the same day to remedy the problem. Managed Health Care Pharmacy comes in quarterly to audit the narcotic books, MARs and the system. RN or designee will audit for discrepancies weekly.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 2 of 3 sampled residents (#s 7 and 8) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 8 was admitted to the facility in 06/2024 with diagnoses including dementia and atrial fibrillation (irregular heart rhythm). The resident’s MAR, dated 06/01/25 through 07/20/25, and signed prescriber orders were reviewed, and interviews with staff were conducted. The following was identified: a. Resident 8 had a signed order dated 05/22/25 for warfarin (blood thinner), 8 mg to be administered Monday, Tuesday, Wednesday, Thursday and Friday, and four mg to be administered Saturday and Sunday. The medication was not administered as ordered on the following dates: * 06/07/25; * 06/15/25; and * 06/16/25. b. Resident 8 had an order dated 06/19/25 to start 8 mg of warfarin every day of the week beginning 06/20/25. The resident received only half of the ordered dose on: * 06/21/25; and * 06/22/25. The resident did not receive any warfarin on: * 06/23/25. c. Resident 8 had an order dated 06/26/25 for the resident to be administered 12 mg of warfarin on Saturday and Sunday, and 8 mg of warfarin Monday, Tuesday, Wednesday, Thursday, and Friday. The resident did not receive the correct dose on: * 06/28/25; and * 06/29/25. The need to ensure all medication orders were carried out as prescribed was reviewed with Staff 1 (Executive Director), Staff 2 (Assistant Executive Director), and Staff 3 (RN) on 07/25/25 at 9:30 am. They acknowledged the findings. ?2. Resident 7 moved into the MCC in 05/2025 with diagnoses including dementia and diabetes mellitus. Resident 7's MAR, dated 06/01/25 to 07/21/25, and corresponding progress notes and prescriber orders were reviewed and revealed the following: * Miralax 17 gm packet was ordered daily for seven days on 05/25/25, after the resident returned to the MCC from the emergency room for a stool blockage. The medication was administered outside prescriber orders from 06/26/25 to 06/30/25, on 07/05/25, and 07/14/25. * Diclofenac sodium 1% gel was ordered for pain twice daily. The medication was not administered on 32 occasions in 06/2025 and on 33 occasions in 07/2025 due to “med not available- backorder,” “new dose not in,” “other- insurance won’t pay for it,” or “med not available- prior authorization needed.” * Nicotine TD DIS 21 mg/24 hour patch (for smoking cessation) was discontinued on 05/06/25 but administered to the resident on 06/19/25, 06/20/25, 06/27/25, 06/28/25, and 07/04/25. * On 04/30/25, blood pressure checks were ordered weekly prior to giving hypertensive medication, with the facility to report systolic readings less than 100. There were no documented blood pressure readings prior to 07/16/25. * Boost Glucose Control shakes were ordered on 04/30/25 each day shift, but there was no documented evidence they were offered. The need to ensure medication and treatment orders were carried out as prescribed was reviewed with Staff 1 (Executive Director), Staff 2 (Assistant Executive Director), and Staff 3 (RN) on 07/25/25 at 11:00 am. They acknowledged the findings.

1. Current, medication and treatment orders obtained from surveyed residents 7 & 8 and sent to the pharmacy. 2. Medication changes and INR appointments reviewed during clinical meeting. Quarterly order reviews will be completed. 3. Daily, monthly, quarterly. 4. Executive director or designee, nursing.

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

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the physician or other legally recognized practitioner was notified when a resident refused to consent to an order for 3 of 3 sampled residents (#s 1, 3, and 5) who had medication refusals. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 09/2022 with diagnoses including dementia. The resident’s 11/01/24 to 11/18/24 MAR and current physician orders were reviewed. The MAR indicated the resident refused the following medications: * Senna (for constipation), on seven occasions between 11/07/24 to 11/17/24; and * Polyethylene glycol (for constipation), on 11/17/24. There was no documented evidence the prescriber was notified of the above medication refusals. At 9:30 am on 11/20/24, Staff 3 (RN) confirmed there was no documentation the prescriber was notified of the medication refusals. The need to ensure the physician or other legally recognized prescriber was notified when a resident refused to consent to an order was discussed with Staff 1 (ED) and Staff 2 (Assistant ED) on 11/21/24. They acknowledged the findings. 2. Resident 5 moved into the facility in 2022 and had diagnoses including dementia and neuropathy. Resident 5's 11/01/24 through 11/18/24 MAR and current physician orders were reviewed. The MAR indicated the resident refused the following medications: * Diclofenac (for neck and back pain) on four occasions; * Atoravastin (for cholesterol) on four occasions; * Gabapentin (for nerve pain) on five occasions; and * Baclofen (for back pain) on four occasions. An interview with Staff 3 (RN) on 11/21/24 at 10:32 am revealed if there was no documentation that the provider was notified of the refusal, “it didn’t happen.” The need to ensure the facility notified the physician or other practitioner if the resident refused consent to an order was discussed with Staff 1 (ED) and Staff 2 (Assistant ED) on 11/21/24 at 2:30 pm. The findings were acknowledged. 3. Resident 1 was admitted to the facility in 11/2022 with diagnoses including type 2 diabetes mellitus and chronic kidney disease. Resident 1's MARs from 10/01/24 through 11/18/24 and corresponding progress notes were reviewed. The resident's records showed the following medication and treatment refusals: * Lactobacillus Rhamnosus (probiotic supplement) on 25 occasions; * Senna 8.6 mg (for constipation) on 31 occasions; * Insulin Glargine (for blood sugar) on six occasions; and * Trelegy Ellipta (breathing treatment) on four occasions. There was no documented evidence the facility notified the physician or other practitioner each time the resident refused to consent to the orders. The need to ensure the facility notified the physician or other practitioner of medication and treatment refusals was discussed with Staff 1 (ED) and Staff 2 (Assistant ED) on 11/21/24 at 3:00 pm. They acknowledged the findings.

The physician was notified of all medications either refused or not given on a daily basis during the work week and requesting to have guidelines how often to be notified of this. We will notify of medications not given or refused per the physician request. RN/LPN will print out the refusal/not given report daily during the work week. The RN or designee.

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

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept for all facility administered medications and the MAR included resident-specific parameters and instructions for PRN medications for 2 of 3 sampled residents (#s 7 and 8) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 7 moved into the MCC in 05/2025 with diagnoses including dementia and diabetes mellitus. Review of Resident 7’s MAR, dated 06/01/25 to 07/21/25, and corresponding progress notes and physician orders revealed the following: a. Resident 7 had the following two prescribed PRN pain medications with RN written parameters: Acetaminophen 325 mg – take two tablets every four hours as needed. Administer first, and if not effective after one hour administer hydrocodone; and Hydrocodone-APAP 5-325 mg – take one tablet by mouth twice daily as needed. Hydrocodone was administered outside of the resident-specific parameters established by the RN on 10 occasions in 06/2025 and 14 occasions in 07/2025. b. The following PRN medication lacked resident-specific parameters: Senna 8.6 mg – take two tablets every twenty-four hours as needed for constipation. The resident was prescribed three other medications for constipation, but there was no instruction in the MAR for the sequential administration of the Senna. c. The resident’s diclofenac sodium 1% gel (for pain) was documented as “refused” 20 times in 06/2025 and twice in 07/2025. In an interview on 07/23/25 at 11:30 am, Staff 2 (Assistant Executive Director) confirmed the medication was not available to the resident during this time due to denial of coverage by insurance and should have been documented as not available. The need to ensure the MAR was accurate and PRN medications contained resident-specific parameters and instructions for administration was reviewed on 07/25/25 at 11:00 am with Staff 1 (Executive Director), Staff 2, and Staff 3 (RN). They acknowledged the findings. 2.Resident 8 was admitted to the facility in 06/2024 with diagnoses including dementia and atrial fibrillation (irregular heart rhythm). Review of Resident 8’s MAR dated 06/01/25 to 07/21/25 and corresponding progress notes and physician orders revealed the following: a. Resident 8 had two PRN medications prescribed for agitation: *Magic Cream, 1 ml to be applied topically every four hours; and *Quetiapine 25 mg, one tablet by mouth four times daily. There was no documented evidence of resident-specific parameters or instructions for the two PRN medications. b. Resident 8 was prescribed PRN trazodone (for sleep), 50 mg, one tablet to be administered by mouth at bedtime. There was no documented evidence of resident-specific parameters or instructions for the PRN medication. The need to ensure PRN medications contained resident-specific parameters and instructions for administration was reviewed with Staff 1 (Executive Director), Staff 2 (Assistant Executive Director) and Staff 3 (RN) on 07/25/25 at 9:30 am. They acknowledged the findings.

1. All prn parameters for surveyed residents 7 & 8 have been reviewed and updated. Med tech education completed on accurate documentation when a medication is not available. 2. All residents MARs will be reviewed and updated to include prn parameters. New medications or medication changes reviewed during clinical meeting. 3. Daily, weekly, quarterly 4. Executive director or designee, nursing.

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

OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications were evaluated upon move-in and at least quarterly thereafter to assure the residents’ ability to safely self-administer medications and had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications for 1 of 1 sampled resident (# 2) who was reviewed for self-administration. Findings include, but are not limited to: Resident 2 was admitted to the facility in 11/2022 with diagnoses including hypertension, depression, and chronic obstructive pulmonary disease (COPD). During the acuity interview on 11/18/24, Resident 2 was identified as self-administering all of his/her medications. This was confirmed by Staff 23 (MT) in an interview on 11/20/24 who stated “s/he started [self-administering] sometime last week.” During the interview with Resident 2 on 11/20/24, s/he stated a family member came every afternoon and prepared the medications for the upcoming day by using a daily pill box. Resident 2 confirmed the self-administration arrangement had been in place “for about a week or something like that.” Neither the resident nor the family member had a list of currently prescribed medications. Resident 2 stated “my [family member] follows the directions written on the bottles or medication cards.” Two of the medications treated blood pressure, and the related physician orders included blood pressure parameters about which Resident 2 was unclear. Additionally, Resident 2 had a scheduled order for a controlled substance medication to treat chronic pain. Review of Resident 2’s medical records revealed there was no documented evaluation of Resident 2's ability to safely self-administer medications, and no physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications was given. In an interview on 11/20/24 at 12:20 pm, Staff 1 (ED) and Staff 3 (RN) confirmed no physician or other legally recognized practitioner’s written order or self-administration evaluation were available. On 11/21/24, Staff 3 notified the survey team the self-administration assessment of Resident 2 had been completed on 11/20/24, and the resident was unable to safely prepare and administer prescribed medications. Resident 2’s family member transferred all medications and the responsibility of administration to the facility on 11/21/24. The transfer of responsibility was confirmed by Resident 2 on 11/21/24 at 12:16 pm. The need to ensure residents who chose to self-administer their medications were evaluated upon move-in and at least quarterly thereafter to assure the residents’ ability to safely self-administer medications and had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications was reviewed with Staff 1 and Staff 2 (Assistant ED) on 11/21/24 at 3:00 pm. They acknowledged the findings.

For Resident 1, the-self administration of medication was rescinded due to evaluation indicated he was not appropriate for self-administration. All residents wanting to self administer will have an assessment by the RN for self-administering of their medications. If appropriate the RN/LPN will obtain an order for self-administering. The resident will be taught to initial the MAR and follow all needed instructions for this medication. The RCC will be audited weekly for descrepancies and corrections. The RN/LPN or designee will review the audits monthly or sooner if descrepancies are found.

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

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure they accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan for 4 of 5 sampled residents (#s 1, 2, 3, and 5) whose acuity-based staffing tool (ABST) were reviewed. Findings include, but are not limited to: 1. Resident 5 moved into the facility in 09/2022 with diagnoses including dementia and neuropathy. Observations of the resident were made, interviews with staff were conducted, and the 10/09/24 service plan, temporary service plans (TSPs), and Resident 5’s ABST data were reviewed. The following areas were not reflective of the residents current ADL assistance: * How much time is spent ensuring non-drug interventions for behaviors? * How much time is spent monitoring physical conditions or symptoms? * How much time is spent on ambulation, escorting to and from meals or activities? The need to ensure the ABST addressed the amount of staff time needed to provide care was discussed with Staff 1 (ED) and Staff 2 (Assistant ED) on 11/21/24 at 2:30 pm. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 09/2022 with diagnoses including dementia. The resident’s ABST, service plan dated 10/02/24, and temporary service plans dated 08/14/24 to 11/18/24 were reviewed. Observations of the resident were made, and interviews with staff were conducted. The resident’s ABST did not capture care time and care elements in the following areas: * How much time is spent supervising, cueing, or supporting while eating? and * How much time is spent providing two-person transfer assistance? The need to ensure the ABST addressed the amount of staff time needed to provide care was discussed with Staff 1 (ED) and Staff 2 (Assistant ED) on 11/21/24. They acknowledged the findings. 3. Resident 1 was admitted to the facility in 11/2022 with diagnoses including type 2 diabetes mellitus and chronic kidney disease. The resident’s ABST, the service plan dated 11/12/24, and temporary service plans were reviewed. Observations of the resident were made, and interviews with staff were conducted. The resident’s ABST calculation did not incorporate expected care time in the following areas: * How much time is spent responding to call lights? * How much time is spent providing treatments? * How much time is spent supervising, cueing or supporting while eating? * How much time is spent transferring in or out of bed or a chair? The need to ensure the ABST addressed the amount of staff time needed to provide care was discussed with Staff 1 (ED) and Staff 2 (Assistant ED) on 11/21/24 at 3:00 pm. They acknowledged the findings. 4. Resident 2 was admitted to the facility in 11/2022 with diagnoses including hypertension, depression, and chronic obstructive pulmonary disease (COPD). The resident’s ABST and the service plan dated 09/24/24 were reviewed. Observations of the resident were made, and interviews with staff were conducted. The resident’s ABST calculation did not incorporate expected care time in the following areas: * How much time is spent on safety checks, fall prevention? * How much time is spent responding to call lights? * How much time is spent supervising, cueing or supporting while eating? The need to ensure the ABST addressed the amount of staff time needed to provide care was discussed with Staff 1 (ED) and Staff 2 (Assistant ED) on 11/21/24 at 3:00 pm. They acknowledged the findings.

Resident's 1, 2, 3, and 5's ABST was reviewed and corrected to reflect resident needs. The ABST questionaire provided by the state will be handed out to the care-partners quarterly as service plans are updated and with change of conditions. The ABST will be reviewed with the Annual, Quarterly, New Admissions and Change of Condition Service plans. The Assistant ED or designee will audit weekly for 3 weeks then monthly for 3 months.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure they accurately captured care time and care elements that staff were providing to residents for 2 of 3 sampled residents (#s 8 and 9) whose ABST was reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 9 was admitted to the facility in 11/2022 with diagnoses including vascular dementia. The resident’s ABST data was reviewed on 07/21/25, observations of the resident were made, and staff were interviewed. The resident's care time and care elements were not reflective in the following areas: * Repositioning in bed or chair; and * Supervising, cueing, or supporting while eating. In an interview on 07/21/25 at 2:45 pm, Staff 32 (CG) reported Resident 9 needed to be repositioned every two hours, due to a closed wound on his/her left hip. This information was corroborated by additional staff interviews on 07/22/25 and 07/23/25. A temporary service plan dated 07/01/25 instructed staff to “help and monitor [Resident 9] eat all meal times [with] ensures [sic] to help [with the resident’s] weight loss.” Observations of Resident 9 during the lunch meal on 07/22/25 and 07/23/25 showed staff sat with the resident and attempted to feed him/her when s/he did not feed himself/herself. The need to accurately capture care time and elements that staff were providing to the resident was discussed with Staff 1 (Executive Director) and Staff 2 (Assistant Executive Director) on 07/24/25 at 9:55 am. They acknowledged the findings. 2. Resident 8 was admitted to the facility in 06/2024 with diagnoses including dementia and atrial fibrillation (irregular heart rhythm). The resident’s ABST data was reviewed on 07/21/25, as well as the resident’s service plan, dated 06/11/25, and behavioral support plan, updated 06/30/25. Observations of the resident were made, and staff were interviewed. The resident's care time and care elements were not reflective in the following areas: * Monitoring behavioral symptoms; * Monitoring physical conditions/symptoms; * Non-drug interventions for behaviors; * Medication administration; * Cueing while eating; and * Bowel/bladder management. The need to accurately capture care time and elements that staff were providing to the resident was reviewed with Staff 1 (Executive Director), Staff 2 (Assistant Executive Director), and Staff 3 (RN) on 07/25/25 at 9:30 am. They acknowledged the findings.

1. The ABST for surveyed residents 8 & 9 have been updated. 2. With each service plan update the ABST will be reviewed and updated as needed. ABST will reviewed in clinical meetings to capture any change of condition needs. 3. Daily, monthly, quarterly. 4. Executive director or designee

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to complete an acuity-based staffing tool (ABST) to accurately capture care time and care elements that staff were providing to each resident as outlined in each individual service plan for 4 of 4 sampled residents (#s 11, 12, 13, and 14) whose ABST records were reviewed. This is a repeat citation. Findings include, but are not limited to: Review of the facility’s ABST documentation for Residents 11, 12, 13, and 14 revealed care time values which were not reflective or accurate in one or more of the following ADL areas: * Monitoring behavioral conditions or symptoms; * Monitoring physical conditions or symptoms; * Assisting with leisure activities; * Time spent on ambulation, escorting to and from meals or activities; * Ensuring non-drug interventions for behaviors; * Providing non-drug interventions for pain management; * Cueing or redirecting due to cognitive impairment or dementia; * Transferring out of bed or chair; and * Assisting with bowel and bladder management. On 01/22/26 at 11:50 am, the need to maintain an ABST which accurately captured care time and care elements that staff were providing to each resident was discussed with Staff 1 (Executive Director) and Staff 2 (Assistant Executive Director). They acknowledged the findings.

1. The ABST for surveyed residents 11, 12, 13, 14 have been updated. 2. With each service plan update the ABST will be reviewed and updated as needed. ABST will be reviewed in clinical meetings to capture any change of condition needs. 3. Daily, monthly, quarterly. 4. Executive director or designee

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by:

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) evaluation for each resident was updated with significant changes of condition and/or quarterly at the same time the resident’s service plan was updated for 2 of 5 (#s 2 and 5) sampled residents whose ABST data was reviewed. Findings include, but are not limited to: The facility’s ABST data and posted staffing plan were reviewed on 11/19/24 at 1:25 pm. The following was identified: Review of the ABST data for Residents 2 and 5 revealed there was no documented evidence the ABST had been reviewed and updated quarterly and/or with significant changes of condition. Therefore, the ABST did not generate an accurate staffing plan. The need to ensure the ABST evaluation for each resident was updated with significant changes of condition and/or quarterly at the same time the resident’s service plan was updated was discussed with Staff 1 (ED) and Staff 2 (Assistant ED) on 11/21/24 at 2:30 pm. They acknowledged the findings.

Resident's 1, 2, 3, and 5's ABST was reviewed and corrected to reflect resident needs. The ABST questionaire provided by the state will be handed out to the care-partners quarterly as service plans are updated and with change of conditions. The ABST will be reviewed with the Annual, Quarterly, New Admissions and Change of Condition Service plans. The ED will update the posted staffing plans if there are changes weekly. The Assistant ED or designee will audit the ABST questionaire weekly for 3 weeks then monthly for 3 months.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) evaluation was updated and reviewed no less than quarterly at the same time the service plan was updated for 2 of 2 sampled residents (#s 8 and 9) who had a quarterly service plan completed and ten unsampled residents whose ABST evaluation dates were reviewed. This is a repeat citation. Findings include, but are not limited to: The facility’s ABST was reviewed on 07/21/25. The following was identified: Twelve of the residents, including Resident 8, Resident 9, and ten unsampled residents, did not have evidence that ABST evaluation updates were completed at least quarterly at the same time as service plan updates. The need to ensure residents’ ABST evaluations were updated no less than quarterly was reviewed with Staff 1 (Executive Director), Staff 2 (Assistant Executive Director), and Staff 3 (RN) on 07/25/25 at 9:30 am. They acknowledged the findings.

1. The ABST for surveyed residents 8 & 9 have been updated. 2. With each service plan update the ABST will be reviewed and updated as needed. ABST will reviewed in clinical meetings to capture any change of condition needs. 3. Daily, monthly, quarterly. 4. Executive director or designee

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

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly hired direct care staff (#s 15, 17, and 21) completed abdominal thrust training within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed with Staff 8 (Business Office Manager) on 11/21/24. Staff 8 reported abdominal thrust training had not been completed for Staff 15 (CG), hired 10/15/24, Staff 17 (CG), hired 10/15/24, and Staff 21 (MT), hired 08/12/24. The need to ensure all training was completed within the required timeframe was discussed with Staff 1 (ED) and Staff 2 (Assistant ED) on 11/21/24. They acknowledged the findings.

HR notified all staff on mandatory classes not completed. They will be completed by the date certain. All courses have been assigned to Oregon Care Partners and Relias to be completed by staff. HR will audit weekly for incomplete training and if not complete will notify the ED for further action. The ED will audit weekly for completion.

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 3 of 4 newly hired staff (#s 28, 30, and 31) demonstrated competency in abdominal thrust within 30 days of hire. This is a repeat citation. Findings include, but are not limited to: Staff training records were reviewed on 07/23/25. There was no documented evidence Staff 28 (MT/CG), Staff 30 (CG), and Staff 31 (CG), hired 06/18/25, 06/05/25, and 05/07/25, respectively, had demonstrated competency in abdominal thrust within 30 days of hire. A “First Aid for Choking” form had been signed by Staff 31 and Staff 3 (RN) but was not dated. The need for newly hired direct care staff to demonstrate competency in abdominal thrust was discussed with Staff 1 (Executive Director) and Staff 2 (Assistant Executive Director) on 07/24/25 9:55 am. They acknowledged the findings.

1. Surveyed staff 28, 30 & 31 all have documentation with the date, that they have demonstrated competency with abdominal thrusts with the RN. 2. A training audit was completed of all staff for abdominal thrust training. The RN will provide training for anyone not up to date. All new hires during their initial training will complete abdominal thrust training with the RN, to include signatures and date. Human resources will double check and track training. 3. Weekly, monthly 4. Executive director or designee, human resources.

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 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: ?Based on interview and record review, it was determined the facility failed to ensure the re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to: C231, C252, C260, C270, C303, C362, C363, C372, C513, C530, C555, Z155, and H1510.

Refer to C231, C252, C260, C270, C303, C362, C363, C372, C513, C530, C555, Z155, and H1510

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the re-licensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to: Refer to C156, C260, C270, C362, and Z140.

Refer to C156, C260, C270, C362, and Z140

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

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF 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) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF 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 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF 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 accesses to the RCF common-use areas were maintained in good repair. Findings include, but are not limited to: The facility grounds were toured on 11/19/24. Railings and posts on the wraparound deck at the entrance to the RCF had large portions of peeling paint exposing bare and decaying wood. These findings were shared with Staff 1 (ED) and Staff 2 (Assistant ED) on 11/21/24 at 1:55 pm. They acknowledged the railings and posts were not in good repair.

Railings and posts on wrap around deck at the entrance to the RCF have been added to our maintenance program, TEL's and completed. Monthly rounds will be done to check the exterior of the building. This will be recorded in TELs. Monthly Maintenance supervisor or designee.

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF 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) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF 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 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF 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 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: The interior of the facility was toured on 11/19/24. The following areas needed cleaning or repair: 1. The Memory Care Unit * Bare wood and gouges along top of half wall surrounding upper dining room; * Food splatters on chair bases in upper dining room; * Food debris between seat and side of chair in upper dining room chairs; * Peeling and cracked pleather benches and chairs in upper and lower dining rooms and common areas; * Loose metal outlet on wall in upper dining room, by kitchen door; and * Scrapes, gouges, and black streaks on door frames and doors throughout the unit. 2. The Residential Care Unit * Stains on carpeted stairs; and * Missing paint along length of handrails on wooden staircase. These findings were reviewed with Staff 1 (ED) and Staff 2 (Assistant ED) on 11/21/24 at 1:50 pm. They acknowledged the areas needing cleaning and repair.

Bare wood and gouges on wall in upper dining room were added to TEL's. New dining room chairs were purchased and delivered. Benches and chairs to the dining rooms will be replaced. A loose metal outlet, in the upper dining room was added to TELs. Scrapes, gouges and black streaks through out the unit were added to TELs. Stains on carpeted stairs were added to TELs. Missing paint along the length of handrails on wooden staircase in Mansion were added to TELs. Maintenance supervisor will observe monthly. If repairs found they will be added to TELs. The Executive Director or designee.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the interior was kept clean and in good repair and free from unpleasant odors. This is a repeat citation. Findings include, but are not limited to: The interior of the facility was toured on 07/21/25. The following areas needed cleaning or repair: Stains on carpeted stairs in the RCF; Missing paint along length of handrails on wooden and carpeted staircases in the RCF; and Black matter and dead insects were observed in the window tracks of multiple windows in the MCC. There was a consistently pervasive odor of urine throughout the MCC. On 07/24/25 at 11:30 am, the above areas were toured with Staff 1 (Executive Director) and Staff 25 (Maintenance Director), who acknowledged the findings.

1. Stains on carpeted stairs in the RCF have been removed. Missing paint along the handrail and on wooden staircases in RCF will be repainted. The window tracks in MCC have been cleaned. The pervasive odor in MCC has resolved with immediate removal of soiled waste after resident care. 2. Daily walk throughs by manager on duty on the weekends and maintenance during the week to address any cleaning, repairs, or other maintenance issues. A maintenance log is also used to communicate to maintenance any issues staff have identified. 3. Daily, Weekly, Monthly 4. Executive director or designee, maintenance.

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

OAR 411-054-0200 (7)(b-d) Housekeeping and Laundry (b) HOUSEKEEPING AND SANITATION.(A) A RCF 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. When the primary laundry is not in the building or suitable for resident-use, a RCF must provide separate resident-use laundry facilities. A CF is not required to provide resident-use laundry services.(A) Laundry facilities must be operable and at no additional cost to the resident.(B) Laundry facilities must have space and equipment to handle laundry-processing needs. 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) 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.(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, or 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 linens 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 room or 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 shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can 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, and failed to ensure soiled linens and clothing were processed separate from regular linens and clothing and in a closed container. Findings include, but are not limited to: The facility laundry process was observed on 11/20/24 and staff were interviewed. The washing machines had general temperature settings but no device to determine the water temperature. Soiled linens were washed with laundry detergent, which was identified as lacking a chemical disinfectant, and Staff 6 (Housekeeping/Laundry Supervisor) confirmed that no chemical disinfectant was added to the soiled linen. Staff 24 (Housekeeping & Laundry) and Staff 14 (CG) reported in an interview on 11/20/24 at 10:50 am that soiled linen and laundry with fecal matter were washed in the hopper sink and placed in the designated five gallon bucket with a lid. They reported soiled linen and laundry with urine were placed in the large open laundry bins by color, with the regular linen and laundry. Staff 24 and Staff 14 stated they did not know that soiled laundry and linen meant laundry and linen contaminated by an individual’s bodily fluids. The need to process soiled linens and clothing separate from regular linens and clothing, keep soiled linens and clothing in closed containers, and use a chemical disinfectant when washing soiled linens and clothing unless the washer had a minimum rinse temperature of 140 degrees, was discussed with Staff 1 (ED) and Staff 2 (Assistant ED) on 11/21/24 at 1:50 pm. They acknowledged the findings.

Oxivirtb (disinfectant,) was purchased and placed in the laundry locked cabinet to be used by staff Housekeeping supervisor will train staff on proper use of the Oxibirtb. Housekeeping supervisor will alert ED when the product needs ordered. This will be checked daily by the housekeeping supervisor. Executive director or designee.

OAR 411-054-0200 (7)(b-d) Housekeeping and Laundry (b) HOUSEKEEPING AND SANITATION.(A) A RCF 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. When the primary laundry is not in the building or suitable for resident-use, a RCF must provide separate resident-use laundry facilities. A CF is not required to provide resident-use laundry services.(A) Laundry facilities must be operable and at no additional cost to the resident.(B) Laundry facilities must have space and equipment to handle laundry-processing needs. 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) 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.(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, or 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 linens 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 room or 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 shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can 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, and failed to ensure soiled linens and clothing were processed separate from regular linens and clothing and in a closed container. This is a repeat citation. Findings include, but are not limited to: The facility laundry process was observed on 07/21/25, and staff were interviewed. A water heater designated to the laundry room and washing machines maintained a temperature of 120 degrees Fahrenheit. Soiled linens were washed with laundry detergent, which was identified as lacking a chemical disinfectant, and Staff 6 (Housekeeping and Laundry Supervisor) and Staff 41 (Housekeeping and Laundry) confirmed that no chemical disinfectant was added to the soiled linen. Staff 41 reported in an interview on 07/21/25 at 1:30 pm that laundry with fecal matter, urine, and/or blood was washed in the utility sink and placed in the designated five-gallon bucket, which did not have a lid. Residents’ regular laundry and linens were placed in large, open bins and washed with soiled items of the same color. On 07/22/25, Staff 6 confirmed soiled laundry was not washed separately from regular laundry. The need to process soiled linens and clothing separate from regular linens and clothing, keep soiled linens and clothing in closed containers, and use a chemical disinfectant when washing soiled linens and clothing unless the washer had a minimum rinse temperature of 140 degrees, was discussed with Staff 1 (Executive Director) and Staff 25 (Maintenance Director) on 07/24/25 at 11:30 am. They acknowledged the findings.

1. The rinse water temperature is now set at 140 degrees Fahrenheit. Soiled laundry is soaked in a container with a lid and washed separately from regular laundry. 2. A new laundry process was implemented with education provided to staff responsible for processing laundry. A visual process was also posted in the laundry room as a reminder for staff. 3. Daily, monthly 4. Executive director or designee.

OAR 411-054-0200 (7)(b-d) Housekeeping and Laundry (b) HOUSEKEEPING AND SANITATION.(A) A RCF 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. When the primary laundry is not in the building or suitable for resident-use, a RCF must provide separate resident-use laundry facilities. A CF is not required to provide resident-use laundry services.(A) Laundry facilities must be operable and at no additional cost to the resident.(B) Laundry facilities must have space and equipment to handle laundry-processing needs. 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) 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.(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, or 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 linens 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 room or 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 shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture. This Rule is not met as evidenced by:

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. Findings include, but are not limited to: A tour of the facility on 11/19/24 identified the following: 1. Exit door alarms for Mansion unit entry door, Sunny unit entry door, and Country and Memory units secured yard door were inoperable and did not alert staff when the doors were opened. 2. Mansion unit side door did not have an alarm for alerting staff when the door was opened. The need to ensure exit doors were equipped with an alarming device or other acceptable system was discussed with Staff 1 (ED) and Staff 2 (Assistant ED) on 11/21/24 at 1:50 pm. They acknowledged the findings and Staff 1 reported an alarm had been ordered for Mansion side door.

A doorbell has been added to the exit door to Mansion. Mansion unit side door had alarm placed. Sunny, Country and Memory units secured yard door have had code removed and resident's can access the court yard. Door alarms have been repaired. Maintenance supervisor. Monthly in TEL's Executive Director or designee.

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. This is a repeat citation. Findings include, but are not limited to: A tour of the facility on 07/21/25 identified the following: Exit door alarms for the Mansion unit side door, Country Lane’s east exit door (near the bake shop mural) and the Sunny unit entry door did not have an alarm for alerting staff when the door was opened. The need to ensure exit doors were equipped with an alarming device or other acceptable system was discussed with Staff 1 (Executive Director) and Staff 25 (Maintenance Director) on 07/24/25 at 11:30 am. They acknowledged the findings.

1. All exit doors have functioning alarms that sound when doors open. 2. All doors will be tested daily by manager on duty. Any issues will be reported to maintenance. 3. Daily, monthly. 4. Executive director or designee.

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by:

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to provide each individual the right to privacy in his or her own unit and to have personal information posted for multiple sampled and unsampled residents. Findings include, but are not limited to: 1. During the survey of 11/18/24 through 11/21/24 multiple units were observed to have their door propped open. On 11/20/24 at 11:20 am, Staff 12 (CG) stated the doors were open “for safety and to keep an eye on [the residents].” The need to ensure residents were provided with privacy in his or her own unit was discussed with Staff 1 (ED) and Staff 2 (Assistant ED) on 11/20/24 at 2:00 pm. They acknowledged the findings. 2. During the survey of 11/18/24 through 11/21/24 a list of multiple sampled and unsampled residents who received modified diets was observed to be posted on the refrigerator located in the common area of the dining room of the MCC. The need to ensure residents’ personal information was not being posted in public areas of the facility was discussed with Staff 1 (ED) and Staff 2 (Assistant ED) on 11/20/24 at 2:00 pm. They acknowledged the findings.

All resident doors will remain closed unless a resident wants the door proped open. If they want the door open it will be added to the service plan. The diet order form was posted in the hallway to the kitchen where visitors or residents can not see. At the Mandatory All Staff meeting HIPPA and Resident Rights will be reviewed. Dietary Supervisor will check monthly. Executive Director or designee.

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure residents received services in a manner that protected privacy, dignity, and respect related to staff using nicknames to address residents and providing ADL care without privacy. This is a repeat citation. Findings include, but are not limited to: Observations were made between 07/21/25 and 07/25/25. The following was revealed: a. Throughout the survey, multiple staff members were observed addressing sampled and unsampled residents using terms such as “kid,” “honey,” “sweetie,” “papa,” and “sweetheart” in place of the resident’s given name or documented preferred nickname. On 07/22/25 at 9:14 am, an unsampled resident was observed to be addressed by a staff member in the dining room. The resident was resistant to being repositioned, and the staff member told the resident “Sorry honey.” The unsampled resident turned to the staff member and loudly exclaimed “Don’t ‘honey’ me!” On 07/24/25 at 10:16 am, Staff 18 (MT) acknowledged some residents preferred variations of their given name, but no one liked to be called “kid.” b. The MCC had two resident-use bathrooms located in a hallway at the end of two resident apartment corridors and near resident common spaces. The bathrooms included lockable doors, and curtains were used as an extra layer of privacy when providing ADL care. Residents were observed in common spaces throughout the survey. On 07/23/25 at 9:47 am, an unsampled resident was observed to receive toileting assistance from a caregiver with the bathroom door open and curtain partially open. The resident did not receive services in a way that protected his/her privacy because his/her care was visible to all residents and staff near the restroom at that time. The need to ensure residents received services in a manner that protected privacy, dignity, and respect was discussed with Staff 1 (Executive Director), Staff 2 (Assistant Executive Director), and Staff 3 (RN) on 07/25/25. They acknowledged the findings.

1. All staff education completed addressing the requirement for privacy, dignity, and respect when assisting residents. Also calling the resident by their name or preferred name. 2. At least daily walk-throughs of the community by management. If privacy, dignity, or respect is being violated in the moment education and correction will happen. Ongoing staff training will include reminders of resident privacy, dignity, and respect. 3. Daily, weekly, monthly. Executive director or designee.

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. This Rule is not met as evidenced by:

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by: Based on record review and interview, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their unit. Findings include, but are not limited to: Review of records for Residents 3, 4, and 5 revealed no documented evidence the residents had been provided keys to their rooms or had been evaluated for the ability to manage keys to their rooms. An interview with Staff 1 (ED) and Staff 2 (Assistant ED) on 11/20/24 at 2:00 pm revealed residents in the MCC were not provided keys to their unit. The need to ensure all residents were provided keys to their units was discussed with Staff 1 and Staff 2 on 11/20/24 at 2:00 pm. They acknowledged the findings.

Keys have been given to every resident. In memory care keys have been taped to the inside of the closet door. Residents have been informed. Housekeeping Supervisor will audit rooms for keys weekly using the room census form. The audit will be reviewed weekly for completion by ED or designee. The Exexutive director or designee will review audit.

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

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all residents who lived in the facility were provided a key to their unit. Findings include, but are not limited to: Multiple interviews conducted on 01/21/26 and 01/22/26 with unsampled residents in the MCC and RCF indicated they had not been provided with a key to their room and expressed a desire to have one. One resident in the MCC reported that another resident repeatedly entered his/her room without permission and stated he/she wanted a key to prevent uninvited entry. Another resident in the RCF reported he/she had experienced numerous items being stolen from his/her room, had never been provided with a key, and stated he/she wanted a key. In an interview on 01/22/26 at 09:44 am, Staff 1 (Executive Director) reported that only residents that stated they wanted a key to their unit were given keys. Staff 1 reported that no residents in the RCF part of the facility had asked for a key and that in the memory care unit keys had been taped in all closets but not always offered to the residents. There was no documented evidence that each resident had been provided a key to their unit. The need to ensure all residents were provided keys to their units was discussed with Staff 1 and Staff 2 (Assistant Executive Director) on 01/22/26 at 9:44 am. Staff acknowledged the findings.

Keys have been made and given to all residents that wanted them. 2. A form has been made and added to residents record. 3. Keys will be offered at move in 4. Administrator or designee

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

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

Refer to C252

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

OAR 411-057-0140(1) Administration Responsibilities (1) The licensee is responsible for the operation of the memory care community and the provision of person centered care that promotes each resident's dignity, independence, and comfort. This includes the supervision, training, and overall conduct of the staff. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the licensee failed to provide administrative oversight to ensure the operation of the memory care community and the provision of person-centered care that promoted each resident’s dignity, independence, and comfort, including the supervision, training, and overall conduct of the staff. Findings include, but are not limited to: During the first revisit to the re-licensure survey of 11/21/24, conducted 07/21/25 through 07/25/25, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations and system failures. Refer to deficiencies in the report.

Refer to C231, C252, C260, C270, C280, C303, C310, C372, H1510, Z155, Z164.

OAR 411-057-0140(1) Administration Responsibilities (1) The licensee is responsible for the operation of the memory care community and the provision of person centered care that promotes each resident's dignity, independence, and comfort. This includes the supervision, training, and overall conduct of the staff. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight over the operation of the Memory Care Community. This is a repeat citation. Findings include, but are not limited to: During the second re-visit to the re-licensure survey of 11/21/24, conducted 01/20/26 through 01/22/26, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective as evidence by the failure to implement a plan of correction, ensure adequate oversight to correct deficiencies, and the issuance of two new citations. Refer to deficiencies in the report.

Refer to C156, C260, C270, C362.

OAR 411-057-0140(1) Administration Responsibilities (1) The licensee is responsible for the operation of the memory care community and the provision of person centered care that promotes each resident's dignity, independence, and comfort. This includes the supervision, training, and overall conduct of the staff. This Rule is not met as evidenced by:

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C231, C362, C363, C372, C510, C513, C530 and C555.

Refer to responses in C231, C362, C363, C372, 510, C513, C530, and C555

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: ?Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to: C156, C160, C231, C362, C363, C372, C513, C530, and C555

Refer to C156, C160, C231, C362, C363, C372, C513, C530, and C555

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C156, C242, and C362.

Refer to C 156, C 242 and C 362.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by:

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly-hired staff (#s 15, 16, 17 and 21) completed all required pre-service orientation training prior to beginning their job responsibilities, 3 of 3 newly-hired direct care staff (#s 15, 17 and 21) completed all required competency training within 30 days of hire, and 1 of 3 long-term staff (#19) completed annual infectious disease training. Findings include, but are not limited to: Training records were reviewed on 11/21/24 with Staff 8 (Business Office Manager). The following were identified: 1. There was no documented evidence Staff 17 (CG), hired 10/15/24, completed pre-service orientation in resident rights and values of CBC care. 2. There was no documented evidence Staff 16 (Cook/Hostess), hired 10/09/24, completed pre-service orientation in the following areas: * Resident rights and values of CBC care; * Abuse reporting requirements; and * Infectious disease prevention. 3. There was no documented evidence Staff 15 (CG), hired 10/15/24, Staff 17, and Staff 21 (MT), hired 08/12/24, completed pre-service orientation in the following areas: * Environmental factors that are important to a resident’s well-being (e.g., staff interactions, lighting, room temperature, noise, etc.); * Family support and the role the family may have in the care of the resident; and * Use of supportive devices with restraining qualities in memory care communities. 4. There was no documented evidence Staff 15, Staff 17, and Staff 21 demonstrated competency in their job duties within 30 days of hire. 5. There was no documented evidence Staff 19 (CG), hired 05/11/20, completed annual infectious disease training during Staff 19’s most recent annual hire date interval, 05/11/23-05/11/24. The need to ensure all required training was completed within the specified time frames was discussed with Staff 1 (ED) and Staff 2 (Assistant ED) on 11/21/24 at 1:50 pm. They acknowledged the findings.

Staff have been informed of the needed courses to be completed by the date certain. HR keeps a spread sheet to monitor progress and needed courses. HR will check the spread sheet daily and report weekly to the ED. If classes are not completed by the date needed the ED will remove the staff off the floor until completed. Executive Director or designee.

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 2 of 4 newly hired staff (#s 30 and 33) demonstrated competency in all required areas within 30 days of hire; failed to ensure 1 of 2 newly hired staff (#28) who was hired to pass medication demonstrated competency in medication technician duties; and failed to ensure 1 of 3 long-term staff (#18) completed infectious disease training annually. This is a repeat citation. Findings include, but are not limited to: 1. There was no documented evidence Staff 30 (CG) and Staff 33 (MT), hired 06/05/25 and 04/28/25, respectively, demonstrated competency in one or more of the following areas within 30 days of hire: * Conditions that require assessment, treatment, observation, and reporting; and * General food safety, serving, and sanitation. 2. There was no documented evidence Staff 28 (MT) had demonstrated competency in medication technician duties within 30 days of hire. In an interview on 07/24/25 at 9:55 am, Staff 1 (Executive Director) and Staff 2 (Assistant Executive Director) were informed Staff 28 could not be scheduled to work as a MT until competency was demonstrated in all assigned duties and documented. 3. There was no documented evidence Staff 18 (MT), hired 07/20/11, had completed infectious disease training in the time period reviewed, 07/01/24 through 06/30/25. The need to ensure staff demonstrated competency in all assigned job duties within 30 days of hire and completed infectious disease training annually was discussed with Staff 1 and Staff 2 on 07/24/25 at 9:55 am. They acknowledged the findings.

1. Surveyed staff #30 and 33 have completed all required training including competency checklist. Surveyed staff #28 has completed med tech competency checklist. Surveyed staff #18 has completed the annual infectious disease training. 2. Human resources will conduct a training audit of all staff and follow up with anyone who does not have all their training completed. 3. Daily until audit complete then weekly, monthly. 4. Executive director or designee.

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by:

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C252, C260, C270, C282, C302, C303, C305 and C325.

Refer to C252, C260, C270, C282, C302, C303, C305, and C325.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to: C252, C260, C270, C280, C303, and C310.

Refer to C252, C260, C270, C280, C303, and C310.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C260 and C270.

Refer to C 260 and C 270.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by:

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide meaningful activities that promoted or helped sustain the physical and emotional well-being of residents and provide person-centered activities during residents’ waking hours for 3 of 3 sampled residents whose records were reviewed and multiple unsampled residents. In addition, the facility failed to address all required elements in activity evaluations and to create an individualized activity plan based on the evaluation for 2 of 3 sampled residents whose activity evaluations and plans were reviewed. Findings include, but are not limited to: 1. Resident 8 and 9’s current service plans were reviewed during the survey, from 07/21/25 through 07/25/25. Although some of the required activity evaluation elements were addressed in the residents’ service plans, there was inadequate information in one or more of the following areas: * Past and current interests; * Current abilities and skills; and * Adaptations necessary for the resident to participate. There was no documented evidence an individualized activity plan had been developed and/or implemented based on the evaluation for either resident. The need for activity evaluations to address all required elements and for an individualized activity plan to be developed from the evaluation and implemented was discussed with Staff 1 (Executive Director) and Staff 2 (Assistant Executive Director) on 07/24/25 at 9:55 am and on 07/25/25 at 9:30 am. They acknowledged the findings. 2. Observations were made of the facility and the activities provided to residents between 07/21/25 and 07/25/25. The facility included an MCC, which housed 37 residents, and an attached RCF, which housed 14 residents. On 07/24/25 at 3:30 pm, Staff 37 (Activity Director) reported she provided activities for both the MCC and the RCF every Monday through Friday from 8:00 am to 4:30 pm. When asked what activities were offered to residents after 4:30 pm and on weekends, she stated she was unsure, and MCC caregivers didn’t assist residents with activities. On 07/24/25, multiple staff members were interviewed regarding the availability of weekend activities for residents in the MCC. The following was revealed: * Staff 37 did not work weekends, so “nothing” happened on Saturdays; * “Don’t have them [activities on Saturdays or Sundays]”; * “[CGs] try to implement activities on the weekends, but caregivers are too busy”; * Three CGs stated they received no training regarding activities to provide to residents in the MCC; and * Residents had requested weekend activities. The need to ensure meaningful activities were available during residents’ waking hours was discussed with Staff 1 (Executive Director), Staff 2 (Assistant Executive Director), and Staff 3 (RN) on 07/25/25 at 10:39 am. They acknowledged the findings.

1. Surveyed residents 8 & 9 individualized activity plans are updated. Activity director will orgainize and work with care staff to provide meaningful activities for evenings and weekends in MCC and RCF. Activity director is working on updating activities to include ready made activity in a box. 2. Activity director will organize and work with care staff to provide meaningful activities for evenings and weekends in MCC and RC. Activity director will review and update all MCC resident's individual activity plans. 3. Daily, weekly, monthly. 4. Executive director or designee, activity director.

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by:

OAR 411-057-0160(g) Outside Area (g) Access to secured outdoor space and walkways which allow residents to enter and return without staff assistance, except when indicated by OAR 411-057-0170(5)(e). This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to provide access to a secured outdoor space which allowed residents to enter and return without staff assistance, except when indicated by OAR 411-057-0170(5)(e). Findings include, but are not limited to: On 11/19/24 at 10:00 am staff were observed using a code to open the door leading to the MCC yard to take a group of residents outside. At 10:35 am Staff 23 (MT) reported that residents were not allowed outside without staff “because we don’t want them going over the fence.” The need to ensure residents have access to secured outdoor spaces without staff assistance was discussed with Staff 1 (ED) on 11/20/24 at 10:35 am. She acknowledged the findings.

The code was removed from the door and residents are able to gain access to the court yard any time they choose to do so. It was corrected by removing the code. The code will not be placed on the door in the future. Safety Coordinator will check weekly to ensure a code is not added to the door.

OAR 411-057-0160(g) Outside Area (g) Access to secured outdoor space and walkways which allow residents to enter and return without staff assistance, except when indicated by OAR 411-057-0170(5)(e). This Rule is not met as evidenced by:

OAR 411-057-0170(6) Secure Outdoor Recreation Area (6) SECURE OUTDOOR RECREATION AREA. The memory care community must comply with facility licensing requirements for outdoor recreation areas as well as the following standards. These requirements apply to newly endorsed, constructed, or remodeled communities which have construction documents approved on or after November 1, 2010 with the exception of subsections (d) and (e) of this section. (a) The space must be a minimum of 600 square feet or 15 square feet per resident, whichever is greater and is exclusive of normal walkways and landscaping. The space must have a minimum dimension of 15 feet in any direction; (b) Fences surrounding the perimeter of the outdoor recreation area must be no less than six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition; (c) Walkways must meet the accessibility requirements of the Oregon Structural Specialty Code. Walkway surfaces must be a medium to dark reflectance value to prevent glare from reflected sunlight; (d) Outdoor furniture must be sufficient weight, stability, design, and be maintained to prevent resident injury or aid in elopement; and (e) Doors to the outdoor recreation area may be locked during nighttime hours or during severe weather per facility policy. This Rule is not met as evidenced by: ?Based on observation and interview, the facility failed to ensure fences surrounding the perimeter of the outdoor recreation area were no less than six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition. Findings include, but are not limited to: During the acuity interview on 07/21/25, facility staff stated that an unsampled resident had eloped by climbing up and over the chain-link fence in the facility’s outdoor recreation area in 05/2025. The facility stated vertical slats had since been installed in the chain-link to reduce the risk of resident elopement. They confirmed that the resident currently resides in the MCC, in addition to at least three other residents with history or risk of elopement. On 07/21/25 at 3:30 pm, the outdoor recreation area was observed to have an approximately 50 foot stretch of sidewalk enclosed with chain-link fencing which did not have slats installed. The chain-link fence was five feet in height. The fence failed to be six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition. On 07/21/25 at 4:15 pm Staff 1 (Executive Director) and Staff 2 (Assistant Executive Director) acknowledged the findings. At 4:45 pm, they stated that Staff 25 (Maintenance Director) would be installing modifications to ensure the fence reached six feet in height that evening, and that staff would stay in the courtyard to ensure residents did not elope prior to the fence being modified. On 07/22/25 at 8:19 am, the outdoor recreation area pathway identified above was observed to have a smooth wooden fence which reached five feet and seven inches in height. Poultry netting was visible behind the wooden fence as it was previously located on top of the chain link fence, but was not constructed in a way to reduce the risk of elopement. The fence along the 50 foot stretch of pathway continued to be less than six feet in height. The need to ensure fences surrounding the perimeter of the outdoor recreation area were no less than six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition, was reviewed with Staff 1, Staff 2 and Staff 3 (RN) on 07/25/25 at 9:30 am. They acknowledged the findings.

1. The fence height was raised to 6 feet. 2. Walk-throughs around the exterior to ensure fence remains safe and in good repair. 3. Daily, monthly. 4. Executive director, maintenance.

OAR 411-057-0170(6) Secure Outdoor Recreation Area (6) SECURE OUTDOOR RECREATION AREA. The memory care community must comply with facility licensing requirements for outdoor recreation areas as well as the following standards. These requirements apply to newly endorsed, constructed, or remodeled communities which have construction documents approved on or after November 1, 2010 with the exception of subsections (d) and (e) of this section. (a) The space must be a minimum of 600 square feet or 15 square feet per resident, whichever is greater and is exclusive of normal walkways and landscaping. The space must have a minimum dimension of 15 feet in any direction; (b) Fences surrounding the perimeter of the outdoor recreation area must be no less than six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition; (c) Walkways must meet the accessibility requirements of the Oregon Structural Specialty Code. Walkway surfaces must be a medium to dark reflectance value to prevent glare from reflected sunlight; (d) Outdoor furniture must be sufficient weight, stability, design, and be maintained to prevent resident injury or aid in elopement; and (e) Doors to the outdoor recreation area may be locked during nighttime hours or during severe weather per facility policy. This Rule is not met as evidenced by: