Print Inspection: RL002260

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure injuries of unknown cause were promptly investigated to rule out abuse and reported to the local SPD office as required for 1 of 1 sampled resident (#4) whose incidents were reviewed. Findings include, but are not limited to: Resident 4 was admitted to the facility in 06/2024 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's 11/01/24 service plan, 10/22/24 through 01/17/25 progress notes, physician communications, and incident investigations were completed. The resident was noted to have behaviors related to entering other residents’ rooms, invading others space and exit seeking often later in the day. The resident required one staff assistance for ADL care and was able to independently ambulate around the facility with a walker. The resident could make some needs known and had poor safety awareness. Review of the resident's records showed the following: * An incident investigation dated 12/05/24 indicated the resident was found to have discoloration to the right hand. The resident was unable to say what had caused the injury. Staff had no further information on the injury of unknown cause. The investigation indicated abuse and neglect was ruled out but contained no information on how that was done. The facility was asked to report the incident to the local SPD office and provided confirmation of the report prior to exit. The need to ensure all incidents were promptly investigated to rule out abuse and reported when required, was discussed with Staff 1 (ED) and Staff 3 (Wellness Director) on 01/22/25 and 01/23/25. They acknowledged the findings.

1. Self-report made to SPD regarding resident 4’s discoloration to right hand on as identified through survey process. 2. All incidents requiring investigation will be investigated timely. Suspected abuse or abuse that is not able to be ruled out will be reported to SPD per Oregon Abuse and Reporting Guidelines. All-staff in-service conducted by 3/24/25 to review Oregon Abuse and Neglect Reporting guidelines, community process for investigating suspected abuse/neglect, timely reporting to SPD, and chain of command for process. Inservice conducted by 3/24/25 with designated staff regarding process for ruling out abuse and neglect and documentation. 3. Timely 4. WD, RN, AED

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

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction to staff regarding care and services and was consistently implemented by staff for 3 of 3 sampled residents (#s 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 03/2021 with diagnoses including Alzheimer’s disease and edema. Observations of the resident, interviews with staff and review of the service plan, dated 01/17/25, showed the service plan was not reflective of the resident's current care needs, consistently implemented by staff and/or did not provide clear direction to staff in the following areas: * Aggression towards staff with care and agitation with spouse; * Private caregiver and facility staff roles/assistance levels; * Number of staff required for care and behaviors; * Toileting assistance and incontinent care; * Dressing, grooming and hygiene assistance; * Fall risks and resident placing themselves on the floor; * Safety interventions including low bed and a fall mat; and * Edema and elevating legs. The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (ED) and Staff 3 (Wellness Director) on 01/23/25. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 06/2024 with diagnoses including dementia. Observations of the resident, interviews with staff and review of the service plan, dated 11/01/24, showed the service plan was not reflective of the resident's current care needs, was not consistently implemented by staff and/or did not provide clear direction to staff in the following areas: * Toileting assistance and incontinent care; * Activities; * Exit seeking with difficult redirection; * Physical aggression with staff; and * Entering other residents; apartments and invading personal space. The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (ED) and Staff 3 (Wellness Director) on 01/22/25 and 01/23/25. They acknowledged the findings. 3. Resident 2 moved into the facility in 09/2023 and had diagnoses including vascular dementia and osteoarthritis. Observations of the resident, interviews with staff, review of temporary service plans, progress notes from 10/21/24 through 01/21/25, and review of the service plan, dated 01/18/25, showed the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas: * Side rail on bed; * Evacuation ability; * Ability to use call system; and * Environmental factors that impact the resident’s behavior including noise. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 3 (Wellness Director) and Staff 7 (Resident Services Director) on 01/23/25. The staff acknowledged the findings.

1. Resident #3’s service plan was updated with current care needs and clear staff directions including agression towards staff with care and agitation with spouse; private caregiver and facility staff roles/assistance levels; number of staff required for care and behaviors; toileting assistance and incontinent care; dressing, grooming, hygiene assistance; falls risks and resident placing themselves on the floor; safety interventions including low bed and a fall mat; edema and elevating legs. Resident #4’s service plan was updated with current care needs and clear staff directions ncluding toileting assistance and incontinent care; activities; exit seeking with difficult redirection; physical aggression with staff; entering other residents apartments and invading personal space. Resident #2’s service plan was updated with current care needs and clear staff directions including side rail on bed; evacuation ability; ability to use call system; enviornmental factors that impacted the resident’s behavior including noise. 2. Residents will be evaluated prior completing service plans and service plans will be updated to reflect current care needs and clear direction to staff using provided template in electornic healthcare record per Oregon Administrative Rules. 3. Move-in, within 30-days, quarterly, significant change in condition 4. WD, RN, AED

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

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents who had short-term changes of condition were evaluated, resident-specific instructions or interventions were developed and reviewed for effectiveness, and weekly progress documented until resolution for 2 of 4 sampled residents (#s 3 and 4) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 03/2021 with diagnoses including Alzheimer’s disease and edema. The resident's 01/17/25 service plan, 10/17/24 through 01/20/25 progress notes, and physician communications were reviewed. The resident experienced multiple short-term changes without noted progress at least weekly until resolved, lacked resident-specific directions to staff and/or interventions reviewed for effectiveness in the following areas: * Medication changes; * Resident to resident altercations; * Falls; and * Left arm bruising. The need to ensure short-term changes of condition had documentation of weekly progress until resolution, provided clear, resident-specific directions to staff and interventions were reviewed for effectiveness was discussed with Staff 1 (ED) and Staff 3 (Wellness Director) on 01/23/25. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 03/2021 with diagnoses including Alzheimer’s disease and edema. Observations of the resident, interviews with staff, and review of the resident's 11/01/24 service plan, 10/22/24 through 01/17/25 progress notes and physician communications were completed. The resident experienced multiple short-term changes without noted progress at least weekly until resolved, lacked resident-specific directions to staff and/or interventions reviewed for effectiveness in the following areas: * Toe discoloration and nail fungus; * Skin breakdown including blister on second toe of the left foot; * Medication changes; * Cough and cold symptoms; * Resident to resident altercation; and * Resident hit their hand/finger on bathroom bar. The need to ensure short-term changes of condition had documentation of weekly progress until resolution, provided clear, resident-specific directions to staff and interventions were reviewed for effectiveness was discussed with Staff 1 (ED) and Staff 3 (Wellness Director) on 01/22/25 and 01/23/25. They acknowledged the findings.

1. Resident #3 will be evaluated for medication changes, history/current resident to resident altercations, falls and left arm bruising. Unresolved changes will be placed on monitoring with documented progress notes at least weekly until resolve and include directions to staff or interventions reviewed for effectiveness. Resolved changes will be documented as resolved and service plan updated to reflect interventions and effectiveness of interventions. Resident #4 will be evaluated for toe discoloartion and nail fungus; skin breakdown including blister on second toe of the left foot; medication changes; cough and cold symptoms; resident to resident altercation; history of resident hittig her hand/finger on bathroom bar. Unresolved changes will be placed on monitoring with documented progress notes at least weekly until resolve and include directions to staff or interventions reviewed for effectiveness. Resolved changes will be documented as resolved and service plan updated to reflect interventions and effectiveness of interventions. 2. All short term changes in condition will be identified and monitored. All short-term changes of condition will have documentation of weekly progress until resolution, provide clear, resident specific directions to staff and include review of effectiveness of interventions. Direct Care inservice will be conducted by 3/24/25 regarding identification and monitoring of short term changes in condition. 3. Timely as identified, Weekly 4. WD, RSD, RN

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 assessment was completed timely and documented findings, resident status, and interventions made as a result of the assessment for 1 of 2 sampled residents (#3) who experienced significant changes of condition. Findings include, but are not limited to: Resident 3 was admitted to the facility in 03/2021 with diagnoses including Alzheimer’s disease and edema. Observations of the resident, interviews with staff, review of the service plan, dated 01/17/25, 10/17/24 through 01/20/25 progress notes, physician communications and hospice communications, and 09/02/24 through 12/19/24 weight records were completed. The resident required full assistance of 2-3 staff with his/her ADLs related to resistance to care. The resident was independent with meal intake and able to eat and drink without physical assistance from staff. The resident did intermittently require encouragement with his/her meals. The resident had significant confusion and was unable to consistently communicate needs. The resident’s dementia had progressed along with increased pain, care needs and behaviors. The resident was admitted to hospice services on 01/15/25. Multiple observations of the resident between 01/21/25 and 01/23/25 showed the resident seated in a chair in his/her apartment or laying in his/her bed. The resident spoke in word salad with intermittent full sentences and ate less than 50% of the meals observed. S/he was offered fluids throughout the day and attempts at snacks. The resident was in significant pain on 01/22/25 and 01/23/25, was provided prn medication for pain and was able to rest comfortably. S/he did not awaken for breakfast or lunch on 01/22/25. Weight records for 09/2024 through 12/2024 showed the following: * A weight of 125.8 pounds on 08/27/24 and a weight of 136.4 pounds on 12/19/24. This represented a 10.8-pound weight gain between 09/02/24 and 12/19/24, which constituted a 7.91% gain in three months. There were no weights recorded between September and December 2024 related to resident refusals and behaviors. The facility was no longer attempting to obtain weights on the resident since his/her admission to Hospice on 01/15/25. A weight at the time of survey was not attempted due to resident behaviors, decline and pain. The resident was not interviewed related to his/her dementia. In interviews between 01/21/25 and 01/23/25, Staff 9 (MT), Staff 10 (CG) and Staff 14 (CG) indicated the resident required multiple staff to complete ADL care due to cognitive impairment, resistance to care and refusals. The resident could eat and drink on his/her own once items were delivered. The staff stated the resident did need some encouragement with his/her meals and the resident’s intake was fair. The staff further indicated the resident was offered French toast whenever s/he would not eat much. The resident was almost always willing to eat the French toast. In interviews between 01/21/25 and 01/22/25, Witness 1 (Private CG) and Witness 2 (Family) indicated the resident’s meal intake varied; there were some days that were better than others. The resident loved French toast so that was always available to offer. They indicated the resident could eat and drink on his/her own but did need encouragement to eat and drink at meals and throughout the day. Witness 2 stated the resident received plenty of food and fluids within the context of what s/he would accept. The resident would not be forced to do anything or take anything s/he did not want. In an interview on 01/23/25, Staff 3 (Wellness Director) indicated she had made a note about the resident’s weights on 12/24/24. She did not note a significant gain between the September and December weights. Staff 3 stated she noted the resident had red swollen legs, had been refusing weights, and would not allow the LPN to check his/her lungs. Witness 4 further indicated there was no assessment completed by the RN. The current facility RN was brand new to the facility and had no further information to offer regarding the resident’s weight changes. The facility failed to ensure an RN assessment was completed for the weight gain which documented findings, resident status, and interventions made as a result of the assessment. The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (ED) and Staff 3 (Wellness Director) on 01/23/25. The staff acknowledged the findings.

1. RN will assess resident #3 regarding weight gain and document findings, resident status and interventions made as a result of the assessment. If resident not at baseline, RN will monitor, document resident status and interventions until new baseline established. 2. Resident weights will be obtained, documented and reviewed per company policy. All signticiant weight changes will be reported timely to Registered Nurse. Registered nurse will timely assess residents with signficant weight changes, documenting findings, resident status and interventions made as a result of the assessment. Registered nurse will monitor resident until return to baseline or new baseline obtained. 3. Timely as identified; Weekly until resolved/new baseliine obtained 4. RN

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

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure they had been consistently staffing to the posted staffing plan and failed to have a sufficient number of caregiving staff to meet the 24-hour scheduled and unscheduled needs of residents. Findings include, but are not limited to: During the acuity interview on 01/21/25, the following was identified: * The facility was home to 26 residents in two segregated (North Shore and South Shore) secured units; * Eight residents (four residents each on the North Shore and South Shore units) required a two-person assist for transfers and/or ADL care; * Three residents required cueing, set-up, or feeding assistance; and * Ten residents were identified as having behavioral symptoms requiring staff assistance when having behaviors. On 01/23/25 at 10:15 am, the facility's Acuity Based Staffing Tool (ABST) entries, staff schedule, calculated staffing hours, and posted staffing plans were reviewed with Staff 1 (ED), Staff 3 (Wellness Director) and Staff 7 (Resident Services Director). The staffing plans posted by the facility “as of 01/18/25” was as follows: North Shore Day Shift: 6:00 am to 2:00 pm: One MT and three and a half CGs. Swing Shift: 2:00 pm to 10:00 pm: One MT and two and a half CGs. NOC Shift: 10:00 pm to 6:00 pm: Half MT and one CG. South Shore Day Shift: 6:00 to 2:00 pm: One MT and one and one and a half CGs. Swing Shift: 2:00 pm to 10:00 pm: One MT and One and a half CGs. NOC Shift: 10:00 pm to 6:00 am: A half MT and one CG. The staff schedule, dated 01/14/25 through 01/20/25, was reviewed. On 13 out of 42 shifts, the facility did not meet the posted staffing plan; in addition, the NOC shift failed to have a minimum of two direct care staff scheduled and available at all times whenever a resident required the assistance of two direct care staff for scheduled and unscheduled needs. During interviews conducted on 01/21/25 through 01/23/25 identified the following: * Staff 13 (CG) reported there was not enough staff on the floor to take care of all the residents. *In an Interview on 01/21/25, Witness 2 (Resident 3 Visitor) and Witness 3 (Resident 3 Visitor) indicated staffing has been an issue. Witness 2 and 3 both visited multiple times a day, at all times of day, along with the resident’s spouse. They both stated night shift was a big concern, but the other shifts also did not have enough staff to meet all the resident needs. Witness 3 indicated there had been more than one occasion when there was only one staff on night shift covering the entire unit. The Witnesses both stated the staff available tried their best but there weren’t enough of them. The resident required at least two-person assistance for ADL care and could be resistive to care. Witness 3 further indicated a private caregiver was hired to help care for Resident 3 due to concerns with his/her ADL care. On 01/22/25 at 10:50 am Staff 1, Staff 2 (MC Administrator) via phone, Staff 3, Staff 4 (RN) and Staff 7 acknowledged the care minutes in facility’s ABST for one sampled Resident (#3), and three unsampled residents who required two person assistance was not accurate, and that the NOC shift staffing did not meet the minimum of two direct staff scheduled and available for residents requiring the assistance of two caregivers. The need to have a sufficient number of staff on all shifts to meet all scheduled and unscheduled needs of residents was discussed with Staff 1, Staff 2, Staff 3, Staff 4, and Staff 7 on 01/22/25. They acknowledged the findings.

1. ABST will be reviewed for all residents to ensure that ABST matches current resident needs as identified in service plans. Stafing plan will be posted to reflect ABST. Staff schedule will reflect staffing plan to ensure sufficient number of staff on all shifts to meet all scheudled and unsheduled needs of residents. 2. ABST will be updated timely with every change in service plan to reflect current service plan. Posted staffing plan will be reviewed with any change in service plan and ABST to ensure staff plan and ABST match. Staff schedule will then reflect posted staffing plan. 3. Before move-in; no less than quarterly; change of condition; corresponding to the service plan. 4. AED, WD, RSD

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

OAR 411-054-0037 (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 interview and record review, it was determined the facility failed to ensure their Acuity-Based Staffing Tool (ABST) accurately captured care time and care elements that staff were providing to residents. Findings include but are not limited to: A review of the facility’s ABST revealed the care time and care elements documented for cares provided by staff were not accurate for sampled Residents 3 and 4. During an interview conducted on 01/22/25 at 10:50 am with Staff 1 (ED), Staff 2 (MC Administrator) via phone, Staff 3 (Wellness Director), and Staff 7 (Resident Services Director), Staff 2 reported that three unsampled resident’s ABST did not have the correct number of minutes for provision of care related to the resident’s requiring two-person assistance with transfers and/or cares. On 01/23/25 the need to ensure the ABST accurately captured care time and care elements was discussed with Staff 1, Staff 3 and Staff 7. They acknowledged the findings. Staff 2 updated the ABST to more accurately reflect the resident’s care needs and updated the facilities staffing plan for each of the two separate secured units.

1. Resident #3 and Resident #4 will be evaluated to ensure that their service plan reflects resident current care needs. The ABST will be reviewed and updated as needed to reflect the service plan. 2. See C360 3. Before move-in; no less than quarterly; change of condition; corresponding to the service plan. 4. AED, WD, RSD

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 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to Oregon Fire Code and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to: Six months of fire drill records were reviewed on 01/23/25 and revealed the following: a. Fire drills lacked documentation of one or more of the following components: * Date and time of day; * Location of simulated fire origin; * The escape route used; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Evacuation time period needed; and * Number of occupants evacuated. In an interview on 01/23/25 at 10:40 am, Staff 24 (Plant Operations Director) acknowledged the documentation lacked one or more of the required components. b. The facility failed to provide fire and life safety instruction to staff on alternate months. In an interview on 01/23/25 at 10:40 am, Staff 24 confirmed staff were not provided fire and life safety instruction on alternating months. The need to ensure fire drills were conducted according to Oregon Fire Code with all required components documented, and fire and life safety instruction to staff was provided on alternating months was discussed with Staff 1 (ED) on 01/23/25 at 2:51 pm. She acknowledged these findings

1. All fire drills conducted will include documentation of the following: date and time of fire drill; loaction of simulated fire origin; escape route used; problems encountered and comments relateing toe residents who resisted or failed to participate in the drills; evacuations time period needed; number of accupants evacuated. Fire and life safety instruction to staff was conducted on 01/30/25. 2. Documentation for fire drills will be updated to include required components. A schedule will be created for Fire and Life Safety instruction to staff for alternating months. 3. Monthly 4. POD, AED

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

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure each resident was instructed within 24 hours of admission and re-instructed at least annually in general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside the building or within the fire safe area in the event of a fire. Findings include, but are not limited to: Resident fire and life safety training records were reviewed on 01/23/25 and revealed multiple unsampled residents did not receive fire and life safety instruction within 24 hours of admission or annually. In an interview on 01/23/25 at 10:55 am, Staff 24 (Plant Operations Director) confirmed he was “behind” on instruction to residents at move-in and annually. The need to ensure each resident was instructed within 24 hours of admission and re-instructed at least annually in general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside the building or within the fire safe area in the event of a fire was discussed with Staff 1, (ED) on 01/23/25 at 2:51 pm. She acknowledged these findings.

1. All resident records will be reviewed and those lacking admission or annual fire and life safety training will receive training regarding general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside the building or within the fire safe area in the event of a fire. 2. Resident Fire and Life Safety training will be completed upon admission and annually. Schedule will be placed for annual Fire and Life Safety training. All new admissions will be scheduled and coordinated to ensure timely completion of resident training within 24 hours of admission. Review of documentation will occur to ensure compliance. 3. Upon admission; Monthly; Annually 4. POD, AED

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

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to H1517.

Waterford Grand MC has barn doors in its memory care community and it has been having difficulty finding a solution for adding single lever action locks as required by HCBS rules. It has previously received an extension to compliance and requested an additional extension while OHCA and ODHS negotiate a solution for those communities where adding a lock is not reasonably feasible. Waterford has never heard back regarding the request for an additional extension. Re-survey took place on July 1 and 2, 2025 while we are still waiting to hear about our request. It is our understanding that ODHS is actively working with OHCA on this issue.

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 (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 washers had a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant was used when washing soiled linens. Findings include, but are not limited to: The facility soiled linen room was toured on 01/23/25 and interviews with staff were completed and revealed the following: During interviews with Staff 10 (CG) and Staff 19 (CG) on 01/21/25 they stated incontinent linen was bagged up, taken to the incontinent laundry room, rinsed in the flushing rim sink, and washed in the small washer with detergent added by pressing a button/using the metered detergent. The washing process was confirmed by Staff 8 (Environmental Services Director) on 01/23/25 at 10:03 am who confirmed the laundry detergent did not contain a chemical disinfectant. Staff 24 (Plant Operations Director) and this surveyor took the temperature of the water line feeding into the incontinent laundry room on 01/23/25 at 10:17 am. Over two separate readings, the water reached 120 degrees F and 121.3 degrees F, or nearly 20 degrees less than the required 140 degrees F needed when washing soiled linens without a chemical disinfectant. The need to ensure washers had a minimum rinse temperature of 140 degrees F unless a chemical disinfectant was used was reviewed with Staff1 (ED), on 01/23/25 at 2:51 pm. She acknowledged these findings.

1. A chemical disinfectant will be added to water temps less than 140 degrees F when washing all soiled linen. 2. From this point forward, the system is corrected by the addition of a chemical disinfectant added to all water temps less than 140 degrees F when washing soiled linen. All direct care staff and house keeping staff will be inserved by 3/24/25 regarding use of chemical disinfectant when washing soiled linens. System will be reviewed for compliance. 3. Monthly 4. Environmental Services Director; POD

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:

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure privacy and dignity related to no locks on bathroom doors for residents who had shared bathrooms. Findings include, but are not limited to: Observations on 01/21/25 of shared bathrooms revealed there was no locking mechanisms on shared bathroom doors to ensure privacy. On 01/23/25, the observations and the need to ensure shared bathroom doors had locks were reviewed with Staff 1 (ED), Staff 2 (MC Administrator) via phone, Staff 3 (Wellness Director), Staff 4 (RN), and Staff 7 (Resident Services Director).

1. All resident shared bathroom doors will be updated with locking mechanism to ensure privacy. 2. System will be corrected once locking mechanism is installed. Unscheduled maintenance will be performed as needed. 3. Timely for unscheduled maintenance 4. POD

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure privacy and dignity related to the absence of locks on bathroom doors for residents who shared bathrooms. This is a repeat citation. Findings include, but are not limited to: In an interview on 07/01/25, Staff 1 (ED), reported that locks had not yet been installed on bathroom doors that were shared by residents. Observations during the survey confirmed that there were no locking mechanisms on shared bathroom doors to ensure privacy. On 07/02/25, the need to ensure shared bathroom doors had locks was reviewed with Staff 1 (ED), Staff 25 (MC Administrator), and Staff 26 (Wellness Director). They acknowledged the findings.

Refer to H1517

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure privacy and dignity related to the absence of locks on bathroom doors for residents who shared bathrooms. This is a repeat citation. Findings include, but are not limited to: In an interview on 07/01/25, Staff 1 (ED), reported that locks had not yet been installed on bathroom doors that were shared by residents. Observations during the survey confirmed that there were no locking mechanisms on shared bathroom doors to ensure privacy. On 07/02/25, the need to ensure shared bathroom doors had locks was reviewed with Staff 1 (ED), Staff 25 (MC Administrator), and Staff 26 (Wellness Director). They acknowledged the findings.

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

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, C360, C362, C420, C422, C530, and H1517.

Refer to C231, C360, C362, C420, C422, and H1517

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 H1517.

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 H1517.

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 2 sampled newly hired staff (#s 20 and 22) completed all required pre-service orientation prior to performing any job duties, 2 of 4 long-term direct care staff (#s 9 and 17) lacked 16 hours of annual in-service training, including six hours related to dementia care, and 6 of 6 long-term staff (#s 7, 9, 15, 16, 17, and 18) lacked infectious disease training. Findings include, but are not limited to: Staff training records were reviewed on 01/23/25. The following deficiencies were identified: 1. Staff 20 (CG) and Staff 22 (CG) hired 09/26/24 and 11/12/24, respectively, failed to have documented evidence of completing one or more of the following pre-service orientation trainings prior to beginning job duties: * Infectious Disease Prevention; * Approved HCBS course; and * Approved LGBTQ2S+ course. 2. Staff 17 (CG), and Staff 9 (CG), hired 04/12/17 and 09/22/22, respectively, failed to have documented evidence of the required 16 hours of annual training, including six hours of dementia care training. 3. Staff 7 (MT), Staff 9, Staff 15 (Life Enrichment Director), Staff 16 (Housekeeper), Staff 17, and Staff 18 (CG) failed to have documented evidence of the required annual infectious disease training. The need to ensure newly hired staff completed all required pre-service orientation prior to performing any job duties, and long-term staff completed the 16 hours of required annual in-service training, including six hours of dementia care training and/or infectious disease training was reviewed with Staff 1 (ED), on 01/23/25 at 2:51 pm. She acknowledged the findings, and no additional documentation was provided.

1. All staff training files will be audited for required pre-service orientation training including infectious disease prevention; approved HCBS course and approved LGBTQ2S+ course. All staff files will be audited for the required 16 hours of annual training, including six hours of dementia care training and annual infectious disease training. All staff identified with missing training will have training assigned and completed. 2. All staff will complete the required pre-service orientation prior to performing job duties. Training documentation will be reviewed prior to staff performing job duties or being scheduled for shifts. Tracking tool will be implemented to track annual trainings and reviewed for compliance. 3. Prior to performing job duties; quarterly; annually 4. BOM, RSD, AED

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: C260, C270, and C280.

Refer to C260, C270, and C280

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 interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose records were reviewed. Findings include, but are not limited to: Residents 1, 2, 3, and 4's records were reviewed during the survey. There was no documented evidence the facility had fully evaluated and developed individualized plans based on the residents’: * Current interests; * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate in activities; and * Identified activities for behavior interventions. There were no specific individualized activity plans which detailed what, when, how, and how often staff should offer and assist each resident with individualized activities. On 01/23/25, the need to ensure residents were evaluated and had an individualized activity plan was discussed with Staff 1 (ED), Staff 2 (MC Administrator), Staff 3 (Wellness Director), Staff 4 (RN), and Staff 7 (Resident Services Director). They acknowledged the findings.

1. Residents #1, #2, #3 and #4 will have full evaluation with developed individualized person-centered plans based on their respective: current interests; current abilities and skills; emotional and social needs and patterns; physical abilities and limitations; adaptions necessary for the resident to participate in activites; and identify activites for behaviour interventions. Individualized activity plans will include detailed what, when, how and how often staff should offer and assist each resident with individualized activity. 2. All residents will be evaluated according to licensing rules prior to admission and as needed for meaningful activities that promote or help sustain physical and emotional well-being. Individualized activity plans will be developed based off initial evaluation and evaluated/updated with all service plan updates or changes in condition to ensure plan still promotes and sustains the residents physical and emotional well-being. 3. Upon move-in, quarterly, change in condition, corresponding to service plan. 4. WD, RSD, LED, AED

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: