Print Inspection: RL002421

OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the licensee failed to ensure adequate administrative oversight of operations which included supervision and training of staff. The facility’s failure to ensure quality of services provided to residents and to ensure supervision and oversight to staff performing job duties put other residents’ health and safety at risk. Findings include, but are not limited to: 1. During the relicensure survey, conducted 01/27/25 through 01/30/25, administrative oversight to ensure adequate resident care and services rendered in the facility were found to be ineffective based on the scope, severity and number of citations. Situations during the survey were identified which posed a risk to residents' health and safety and constituted and immediate plan of correction in the following area: C160: OAR 411-054-0025 (4) Facility Administration: Operation. An Immediate plan of correction was requested on 01/28/25 at 2:57 pm. The facility provided a plan of correction on 01/28/25 at 5:30 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation. 2. Refer to deficiencies in the report.

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

OAR 411-054-0025 (9) Facility Administration: Quality Improvement (9) QUALITY IMPROVEMENT PROGRAM. The facility must develop and conduct an ongoing quality improvement program that evaluates services, resident outcomes, and resident satisfaction. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to develop and conduct an ongoing quality improvement program that evaluated services, resident outcomes, and resident satisfaction. Findings include, but are not limited to: During the relicensure survey, conducted 01/27/25 through 01/30/25, the quality improvement oversight for ensuring adequate resident care, services, and satisfaction was found to be ineffective as evidenced by the number and severity of the citations. In an interview on 01/30/25 at 5:40 pm, with Staff 1 (Administrator), it was confirmed the facility did not have a quality improvement or quality assurance program in place or implemented. The need to ensure the facility conducted an ongoing quality improvement program that evaluated services, resident outcome and satisfaction was discussed with Staff 1 and Staff 2 (Assistant Administrator) on 01/30/25. They acknowledged the findings.

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

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition which could threaten the health, safety, or welfare of residents for 1 of 1 sampled resident (#3) and two unsampled residents who were known to have smoked in their rooms. This placed residents at risk and constituted an immediate threat to the residents' physical safety and well-being. Findings include, but are not limited to: During the acuity interview on 01/27/25, it was reported that several residents were smokers, and two residents used oxygen. At the time of the survey, the facility had 32 residents. Resident 3 moved into the facility in 06/2022 with diagnoses including Alzheimer’s disease and nicotine dependence. On 01/27/25 at 3:25 pm, the survey team noticed a strong smell of smoke that intensified over time. The survey team noted the smell was originating from Resident 3’s room. The survey team alerted a Resident Aide who proceeded to walk with the surveyors to Resident 3’s unit and open the door. The surveyor and caregiver observed plumes of smoke in the air and a pervasive odor of cannabis smoke in the air. The surveyor requested the caregiver immediately report to management. At 3:33 pm, Staff 2 (Assistant Administrator) confirmed that two residents had been smoking cannabis in the room. She reported the residents were informed to smoke outside. On 01/27/25 at approximately 4:00 pm, Staff 18 (Housekeeper) reported she was aware Resident 3 had been smoking in their room. Additionally, she mentioned that two other residents had smoked in their rooms. Staff 18 and the surveyor walked through the facility, identified the room numbers and the resident’s names, and confirmed that the three residents were known to have smoked in their rooms. On 01/28/25 at approximately 9:46 am, Staff 13 (Resident Aide) and Staff 15 (Resident Aide) reported Resident 3 occasionally smoked in his/her room and that incidents were reported to the Administrator. When asked how frequently residents smoked in their rooms, they reported it occurred approximately two or more times per week. On 01/28/25 at 11:10 am, Staff 14 (Med Aide) reported she was aware that Resident 3 smoked in the room. Staff 14 reported the resident mentioned it was too cold outside or forgot not to smoke in the room. She further stated it happened approximately one or two times per month. She reported when the resident smoked in the room, she repeatedly spoke to the resident, informing them of the consequences and provided education on the issues. However, she confirmed there was no documented evidence of her interactions, including the dates of the incidents or any notes regarding the resident smoking in the room. Resident 3’s smoking evaluation, dated 01/21/25, indicated the resident required “reminders to go out to smoke when getting [his/her] cigarette.” However, the service plan, updated 01/21/25, did not include any information about the resident’s smoking status, such as whether the resident was independent, required prompts or needed assistance with smoking. The service plan indicated the resident would occasionally go outside to smoke and socialized with a few other residents and staff. It was determined that staff were aware of the residents smoking in their rooms, an issue that had occurred multiple times in the past. The facility's failure to address indoor smoking put Resident 3 and other residents at risk and constituted an immediate threat to the residents' health, safety, or welfare. An immediate plan of correction was requested on 01/28/25 at approximately 2:57 pm. The facility provided a plan of correction that was accepted on 01/28/25 at 5:30 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation. The need to ensure the facility exercised reasonable precautions against any condition which could threaten the health, safety, or welfare of residents was discussed with Staff 1 (Administrator) and Staff 2 on 01/28/25 at 5:30 pm. They acknowledged the findings.

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

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure physical injuries of unknown cause were reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concluded and documented that the physical injury was not the result of abuse, and failed to ensure investigations documented place and individuals present; a clear description of the event; and follow-up action needed for 2 of 2 sampled residents (#s 2 and 3) with documented injuries of unknown cause and falls with injuries. Findings include, but are not limited to: Resident 2 moved into the residential care community in 10/2018 with diagnoses including schizoaffective disorder, bipolar disorder and dementia with behavioral disturbance. The resident’s evaluation and service plan noted Resident 2 was nonverbal. Progress notes and facility documented investigations on resident incident reports from 10/27/24 through 01/27/25 were requested and reviewed during the survey. The following injuries of unknown cause were identified: * 11/08/24 – Cut on right hand middle finger; and * 11/21/24 – Wound on the bottom of the left foot. These represented injuries of unknown cause and required reporting to the local SPD office unless an immediate investigation determined the injuries were not the result of abuse. There was no documented evidence the facility immediately investigated and documented the injuries were not the result of abuse. The facility did not report the skin injuries to the local SPD office as suspected abuse. b. The following falls were identified: * 12/12/24 – Unwitnessed fall with injuries. Resident 2 was sent to the emergency room and returned to the community nine days later. An incident report was initiated on 12/16/24 (four days later) and failed to include a clear description of the incident including the location of where the incident occurred and the follow up action taken by facility staff. * 01/16/25 – Witnessed fall in the bathroom. The incident report noted “care staff said the resident fell on [his/her] side. Then got up without a problem.” The investigation lacked information of whether the service plan was being followed, any follow up action necessary to reduce future incidents and a clear description of the incident. Survey requested the facility self-report the above incidents to the local SPD office on 01/30/25 at 8:40 am. Verification was received by email after survey exit on 01/31/25. The need to ensure immediate investigations were completed, included all required components of an investigation, and ruled out suspected abuse or were reported to the local SPD office was discussed with Staff 1 (Administrator), Staff 2 (Assistant administrator), and Staff 5 (RN) on 01/30/25 at 1:34 pm. Resident 3 was admitted to facility 06/2022 with diagnoses including Alzheimer’s disease and type II diabetes. A review of Resident 3's progress notes indicated an alert on 01/19/25 regarding a blister on the top of the left big toe. On 01/30/25 at approximately 10:25 am, Staff 2 (Assistant Administrator) confirmed there was no investigation showing how the facility determined the cause of the skin injury or whether it resulted from neglect or abuse. The incident was not reported to the local SPD office. This represented an injury of unknown cause and required reporting to the local SPD office unless an immediate investigation determined the injury was not the result of abuse. Survey requested the facility to report the skin injury to the local SPD office. The facility informed the survey team that it had reported the incident to the local office via phone on 01/30/25 at 5:15 pm. The need to investigate all incidents to rule out suspected abuse and report to the local SPD office if abuse could not be ruled out, was discussed with Staff 1 (Administrator) and Staff 2 on 01/30/25 at 5:15 pm. They acknowledged the findings.

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

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure a move-in evaluation addressed all required elements for 1 of 1 sampled resident (# 4) and failed to accurately describe the resident's current status and condition for 1 of 3 sampled residents (# 2) whose quarterly evaluation was reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 11/2024 with diagnoses including emphysema. The resident's 10/2024 move-in evaluation was reviewed. There was no documented evidence the following elements were evaluated: To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: Name; Pronouns; and Gender identity. The need to evaluate all required areas of the move-in evaluation was reviewed with Staff 1 (Administrator), Staff 2 (Assistant Administrator) and Staff 5 (RN) on 01/30/25 at 5:05 pm. They acknowledged the findings. 2. Resident 2 moved into the facility in 10/2018 with diagnoses including schizoaffective disorder, bipolar disorder and dementia with behavioral disturbance. The resident’s evaluation and service plan noted the resident was nonverbal. Resident 2’s quarterly evaluation dated 12/26/24 was reviewed and interviews with staff were conducted during the survey. The quarterly evaluation failed to accurately describe the resident's current status and condition in the following areas: * Social interests, hobbies, activities; * Bladder/bowel management; * Communication and sensory needs; * Cognition including orientation, confusion and decision making; * Personality and how the resident copes with challenging situations; * Mental status and ability to know one's own limits; * Behavior expressions including triggers and interventions to support the resident; * Fall risk; * Weight loss; * Cannabis use; and * Environmental factors that impact a resident’s behavior. The need to ensure the quarterly evaluation was reflective of the resident's current status and condition was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), and Staff 5 (RN) on 01/30/25 at 1:34 pm. They acknowledged the findings.

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

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding care and services for 3 of 3 sampled residents (#s 1, 2, and 3) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 10/2018 with diagnoses including schizoaffective disorder, bipolar disorder and dementia with behavioral disturbance. Observations of the resident, interviews with staff and review of the service plan, dated 12/26/24, and subsequent Temporary Service Plans (TSP’s) identified the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas: * As needed eating assistance, including one-on-one physical assistance with utensils and bringing cups to edge of mouth; * Bladder/bowel management including the number of care staff needed to support the task and how frequently the task should be completed; * Mental status including cognition, orientation, confusion and decision making; * Personality and how the resident coped with challenging situations including how s/he coped with challenges from other residents in the community; * Resistive to care, including dressing, toileting, showers, personal hygiene; * Safety checks and fall interventions; * Weight loss and interventions; * Cannabis use and smoking status; and * Environmental factors that impact behavior, including but not limited to: noise, lighting and temperature. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), and Staff 5 (RN) on 01/30/25 at 1:34 pm. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 06/2019 with diagnoses including bipolar disease and seizure. Observations of the resident, interviews with the resident and staff, and review of the service plan, dated 01/07/25, showed the service plan was not reflective of the resident’s current care needs and did not provide clear direction to staff in the following areas: * Fall risk, including fall interventions; * Smoking status; * Dressing; * Transfers; * Use of bathroom or bedside commode, including cleaning after use; and * Shower status. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator) on 01/29/25 at 1:35 pm. The staff acknowledged the findings. 3. Resident 3 was admitted to the facility in 06/2022 with diagnoses including Alzheimer’s disease and type II diabetes. Observation of the resident, interview with the resident and staff, and review of the service plan, dated 01/21/25, showed the service plan was not reflective of the resident’s current care needs and did not provide clear direction to staff in the following areas: * Smoking status including whether the resident was independent, required prompts or needed assistance with smoking; * Skin status; and * Behaviors including refusal of shower and urinating in inappropriate areas. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator) on 01/29/25 at 2:05 pm. The staff acknowledged the findings.

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

OAR 411-054-0036 (5) Service Plan: Service Planning Team (5) SERVICE PLANNING TEAM. The service plan must be developed by a Service Planning Team that consists of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident. Involved family members and case managers must be notified in advance of the service-planning meeting.(a) As applicable, the Service Planning Team must also include:(A) Local APD or AAA case managers and family invited by the resident, as available.(B) A licensed nurse if the resident shall need, or is receiving nursing services or experiences a significant change of condition as required in 411-054-0045(1)(f)(D) (Resident Health Services).(C) The resident's physician or other health practitioner.(b) Each resident must actively participate in the development of the service plan to the extent of the resident's ability and willingness to do so. If resident participation is not possible, documentation must reflect the facility's attempts to determine the resident's preferences. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the service plan was developed by a service planning team consisting of the resident, the resident’s legal representative, if applicable, any person of the resident’s choice, the facility administrator or designee, and at least one other staff person who was familiar with, or who was going to provide services to the resident for 3 of 3 sampled residents (#s 1, 2, and 3). Findings include, but are not limited to: Records for Residents 1, 2, and 3 were reviewed. There was no documented evidence of a service planning team. On 01/29/25 at 1:35 pm, Staff 1 (Administrator) confirmed the resident had not been involved in the service planning. The need to ensure a service planning team was used to update service plans was discussed with Staff 1 and Staff 2 (Assistant Administrator) on 01/29/25 at 1:35 pm. They acknowledged the findings.

OAR 411-054-0036 (5) Service Plan: Service Planning Team (5) SERVICE PLANNING TEAM. The service plan must be developed by a Service Planning Team that consists of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident. Involved family members and case managers must be notified in advance of the service-planning meeting.(a) As applicable, the Service Planning Team must also include:(A) Local APD or AAA case managers and family invited by the resident, as available.(B) A licensed nurse if the resident shall need, or is receiving nursing services or experiences a significant change of condition as required in 411-054-0045(1)(f)(D) (Resident Health Services).(C) The resident's physician or other health practitioner.(b) Each resident must actively participate in the development of the service plan to the extent of the resident's ability and willingness to do so. If resident participation is not possible, documentation must reflect the facility's attempts to determine the resident's preferences. This Rule is not met as evidenced by:

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure changes of condition were evaluated, interventions were determined, documented, communicated to staff, and were monitored weekly through resolution for 3 of 3 sampled residents (#s 1, 2, and 3) who experienced changes of condition. Resident 1 experienced a fall resulting in a compression lower back fracture following multiple falls without interventions or monitoring. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 06/2019 with diagnoses including unspecified fall, bipolar disorder and seizure. During the survey, the resident was observed spending most of the day in bed and calling for assistance when needed. Staff were observed checking on the resident frequently. a. During the acuity interview on 01/27/25, the resident was identified as having experienced multiple falls and had been diagnosed with a new lower back fracture resulting from one of the falls. The resident's clinical records including service plan, Temporary Service Plans (TSP’s), progress notes, and investigations were reviewed during the survey. Resident 1's progress notes, dated 11/01/24 through 01/23/25 and investigations, dated 11/01/24 through 01/19/25, were reviewed during the survey and the following was noted: * 11/01/24: Unwitnessed fall in the room, noninjury. Staff documented the resident reported losing his/her balance; * 11/07/24: Unwitnessed fall in the room, noninjury. Staff documented the resident was getting out of bed and missed his/her wheelchair; * 11/25/24: Unwitnessed fall in the hallway, resulted in shoulder pain. Staff documented the resident fell from his/her wheelchair while going down the ramp into the hallway; * 12/24/24: Unwitnessed fall in the room, noninjury. Staff documented the resident reported transferring from bed to wheelchair, losing balance and falling onto his/her buttocks; * 01/07/25: Unwitnessed fall in the hallway, resulted in lower back pain. Staff documented the resident fell backward while going up the ramp toward the lobby area; and * 01/13/25: The resident was crying, expressing severe back pain from a fall the previous week and requested to call 911. The resident returned to the facility with a new diagnosis of a compression fracture and prescribed pain medication. On 01/07/25 the facility RN documented in her assessment that the resident exhibited increased behaviors, tended to be manipulative, and was more prone to falls when the resident lacked consistent reminders to call for assistance if s/he felt weak, unsteady, or needed help using the ramp. However, the information had not been communicated to staff. The evaluation and service plan dated 01/07/25 had the following fall interventions: Standby for bathing and offer assistance at the times s/he was awake and in his/her wheelchair with walking up and down the hall. Throughout the survey, multiple staff reported they reminded the resident to call for help when needed. However, when asked about other interventions to prevent falls, it was unclear if any were in place. A review of the resident’s clinical records revealed no documented evidence the facility investigated the root cause of the falls or developed resident-specific interventions to help minimize future falls. Additionally, there was no documented evidence the changes of condition were monitored through resolution. The facility's failure to evaluate the resident after each fall, determine actions or interventions, communicate the interventions to staff, and monitor the effectiveness of previously established fall interventions put the resident at risk for repeated falls, resulting in a fall with a compression fracture. The need to ensure residents who experienced a change of condition were evaluated and resident-specific actions or interventions were developed, communicated to staff, and monitored through resolution was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator) on 01/29/25 at 1:35 pm. They acknowledged the findings. b. Resident 1's clinical record noted the following: * 01/02/25: Right third and fourth toe, open skin area; * 01/13/25: Emergency room visit and returned to the facility with a new diagnosis of compression fracture, vertebra, left side; * 01/13/25: Increased oxycodone pain medication dose; and * 01/19/25: Emergency room visit due to severe pain in stomach, lower back and returned to the facility with a new medication of Cyclobenzaprine, a muscle relaxer. There was no documented evidence the changes of condition were monitored through resolution. The need to ensure residents who experienced a short-term change of condition were monitored through resolution was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator) on 01/29/25 at 1:35 pm. They acknowledged the findings. 2. Resident 3 moved into the facility in 06/2022 with diagnoses including, Alzheimer’s disease and type II diabetes. Resident 3's progress notes, dated 11/05/24 through 01/27/25 and a 12/27/24 Temporary Service Plan (TSP) were reviewed during the survey and the following was noted: * 11/19/24: A new daily Aspirin for toe discoloration; and * 12/27/24: A new medication, lisinopril and an increase in the scheduled insulin dose. There was no documented evidence the changes of condition were monitored through resolution. The need to ensure residents who experienced a short-term change of condition were monitored through resolution was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator) on 01/29/25 at 2:05 pm. They acknowledged the findings. 3. Resident 2 moved into the facility in 10/2018 with diagnoses including schizoaffective disorder, bipolar disorder and dementia with behavioral disturbance. Observations of the resident, interviews with staff, review of progress notes and Temporary Service Plans (TSP’s) identified the following changes of condition: * 10/16/24 – Start meloxican and discontinue oxycodone (both medications were for pain management); * 11/08/24 – Skin tear left hand middle finger; * 11/19/24 – Involuntary muscle jerks in both arms; * 11/21/24 – Left foot wound, half dollar size and left big toe causing pain; * 12/12/24 – Unwitnessed fall; * 12/21/24 – Returned to community from a hospital stay; and * 01/16/25 - Witnessed fall. The above changes of condition lacked information in the resident’s record regarding what action or interventions were determined by the facility, communication of the determined actions or interventions to staff on each shift, and/or that the conditions were monitored at least weekly with progress noted in the resident’s record until the conditions resolved. The need to ensure the facility determined action or interventions needed for changes of condition, communicated the determined action or interventions to staff on each shift, and monitored the resident at least weekly through resolution was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), and Staff 5 (RN) on 01/30/25 at 1:34 pm. They acknowledged the findings.

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 completed a significant change of condition assessment for 2 of 2 sampled residents (#s 1 and 2) who experienced significant changes of condition related to weight loss and a fall with fracture. Findings include, but are not limited to: Resident 2 moved into the residential care community in 10/2018 with diagnoses including schizoaffective disorder, bipolar disorder and dementia with behavioral disturbance. Observations of the resident during the lunch meal service on 01/27/25 identified the resident was able to eat and drink independently and consumed 100% of the meal and had two glasses of milk. During an interview on 01/27/25 at 12:10 pm with Staff 12 (Resident Aide) it was reported Resident 2 ate well today; however, s/he didn’t always eat independently. Usually s/he required staff to sit with him/her and physically assist with eating and drinking. An evaluation and service plan dated 12/26/24, Temporary Service Plans (TSP’s), progress notes and weight records were reviewed during the survey. The following was identified: * 07/05/2024: 174.8 pounds; * 08/05/2024: 156.2 pounds; * 09/05/2024: 161.2 pounds; * 10/05/2024: 160.4 pounds; * 11/2024: No weight was recorded; and * 12/05/2024: 156.8 pounds. Between 07/05/24 to 08/05/24, Resident 2 had a weight loss of 18.6 pounds or 10.64% of his/her total body weight. This constituted a severe weight loss within one month. This severe weight loss represented a significant change of condition and required an RN assessment. During an interview on 01/28/25 at 4:30 pm, an RN assessment for Resident 2’s severe weight loss was requested. There was no documented evidence the RN completed a significant change of condition for Resident 2’s severe weight loss. The need to ensure an RN assessment was completed for residents who experienced significant or severe weight loss was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), and Staff 5 (RN) on 01/30/25 at 1:34 pm. They acknowledged the findings. 2. Resident 1 moved into the facility in 06/2019 with diagnoses including unspecified fall, bipolar disorder and seizure. During the survey, the resident was observed spending most of the day in bed and calling for assistance when needed. Staff were observed checking on the resident frequently. Resident 1's progress notes, dated 11/01/24 through 01/23/25, investigations, dated 11/01/24 through 01/19/25, and Temporary Service Plans (TSPs) were reviewed during the survey and the following was noted: * 01/07/25: Unwitnessed fall in the hallway. Staff documented the resident falling backward while going up the ramp toward the lobby area; and * 01/13/25: The resident was crying, expressing severe back pain from a fall the previous week and requested to call 911. The resident returned to the facility with a new diagnosis of a lower back compression fracture and was prescribed pain medication. Throughout the survey, multiple staff reported that the resident required additional assistance with transfer, toileting, and showering due to pain from the recent fall. This indicated a significant change in the resident’s condition that required an RN assessment. There was no RN assessment conducted after the resident received a new diagnosis of a compression fracture and required additional assistance with ADLs. The failure to conduct an RN assessment following a significant change in status was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator) on 01/29/25 at 1:35 pm and Staff 5 (RN) on 01/30/25 at 5:05 pm. They acknowledged the findings.

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

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to ensure outside service providers left written documentation detailing the on-site services provided to the resident and any necessary clinical information to support facility staff in delivering supplemental care for 1 of 1 sampled resident (#3) who received home health nursing services. Findings include, but are not limited to: During the acuity interview on 01/27/25, Resident 3 was identified as receiving home health nursing services. On 01/27/25 at 1:15 pm, it was observed that a home health nurse provided dressing changes for the resident. Witness 1 (Home Health Nurse) reported she performed the dressing changes twice a week. During the survey, the facility was asked to provide home health nurse visit notes. While some visit notes were provided, they only documented one visit per month rather than the scheduled twice-weekly visits. On 01/28/25 at 4:10 pm, Staff 2 (Assistant Administrator) reported multiple home health visit notes regarding the resident’s wound care had just arrived via fax. This indicated the facility failed to ensure outside service providers left written documentation detailing the on-site services provided to the resident and any necessary clinical information to support facility staff in delivering supplemental care. On 01/29/25 at 2:05 pm, the above findings were shared with Staff 1 (Administrator) and Staff 2. The staff acknowledged the findings.

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments that the facility was responsible to administer and ensure signed orders were carried out as prescribed for 2 of 3 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 10/2018 with diagnoses including schizoaffective disorder, bipolar disorder, and dementia with behavioral disturbance. The January 2025 MAR and signed orders dated 09/03/24 were reviewed during the survey. During the survey on 01/27/25 signed physician orders were unable to be located in the resident’s record. Staff 1 (Administrator) reported they were requesting the orders from the pharmacy. The facility received a date stamped fax on 01/27/25 and provided the signed physician orders at 4:30 pm on 01/27/25. The need to ensure written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments that the facility was responsible to administer was discussed with Staff 1, Staff 2 (Assistant Administrator), and Staff 5 (RN) on 01/30/25 at 1:34 pm. They acknowledged the findings. 2. Resident 1 moved into the facility in 06/2019 with diagnoses including unspecified fall, bipolar disorder and seizure. The 01/01/25 through 01/27/25 MAR and signed orders, dated 07/11/24, were reviewed during the survey. a. The MAR directed the administration of the following medications: * Artificial tears, one drop in each eye as needed for dry eyes; * Lidocaine 2.5% cream to be applied twice daily as needed for pain; and * Rizatriptan, 10 mg as needed for migraines. There were no signed physician’s order for these medications. b. A physician’s order dated 07/11/24 directed the administration of Tylenol 500 mg, one to two tablets by mouth twice daily at 8:30 am and 8:30 pm. However, the order was not transcribed onto the MAR and was not carried out as prescribed. The need to ensure written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments that the facility was responsible to administer and carried out as prescribed was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator) on 01/29/25 at 1:35 pm. They acknowledged the findings.

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

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure MARs were accurate and included resident-specific parameters and staff instruction for PRN medications for 3 of 3 sampled residents (#1, 2, and 3) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 10/2018 with diagnoses including schizoaffective disorder, bipolar disorder and dementia with behavioral disturbance. The 01/01/25 through 01/27/25 MAR, signed orders dated 09/03/24, and hospital discharge orders dated 12/20/24 were reviewed during the survey. The following was identified: Resident 2 was prescribed PRN quetiapine and PRN risperidone, both for agitation. The 01/2025 MAR lacked resident-specific parameters including the sequence of use for PRN quetiapine and PRN risperidone used to treat the same condition. The need to ensure MARs included resident-specific parameters and staff instructions for PRN medications was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), and Staff 5 (RN) on 01/30/25 at 1:34 pm. They acknowledged the findings. 2.Resident 1 moved into the facility in 06/2019 with diagnoses including unspecified fall, bipolar disorder and seizure. The 01/01/25 through 01/27/25 MAR was reviewed and showed the following: The MAR indicated the resident self-applied Ketoconazole 2% cream for fungal infection. During an interview on 01/28/25 at 11:21 am, Staff 14 (Med-Aide) reported she administered all of the resident’s treatment including Ketoconazole. Staff 14 showed the surveyor the cream, which was kept in the medication cart and confirmed Med-Aides were administering the medication as needed. The need to ensure MARs were kept accurate and provided clear staff instruction was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator) on 01/29/25 at 1:35 pm. They acknowledged the findings. 3. Resident 3 moved into the facility in 06/2022 with diagnoses including Alzheimer’s disease and type II diabetes. The 01/01/25 through 01/27/25 MAR was reviewed and showed the following: The MAR directed staff to assist the resident with putting on and removing Farrow compression socks daily. Staff periodically signed on the MAR that they assisted with putting on and taking off the compression socks. However, based on observation and interviews with staff, it was noted that the staff did not provide this treatment as the compression dressing was managed by the home health nurse twice a week. The MAR instructed staff to document the insulin amount and quantity administered. On two occasions, different and inaccurate information was recorded. During an interview with Staff 2 (Assistant Administrator) on 01/28/25 at 4:10 pm, she acknowledged the insulin amount was documented incorrectly. On 01/29/25 at 2:05 pm, the above findings were shared with Staff 1 (Administrator) and Staff 2. The staff acknowledged the findings.

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

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents per the facility’s Acuity-Based Staffing Tool (ABST) and posted staffing plan. Findings include, but are not limited to: A. Review of the facility's posted staffing plan, schedule from 01/20/25 to 01/27/25, and current ABST indicated the following: * Day Shift: 6:30 am to 3:00 pm - 1 Med-Aide and 2 Caregivers; * Mid Shift : 10:30 am to 7:00 pm (Monday – Saturday) – 1 Caregiver; * Swing Shift: 2:30 pm to 11:00 pm - 1 Med-Aide and 2 Caregivers; * Overnight Shift: 1 Med- Aide and 1 Caregiver; and * Five of seven days reviewed were not staffed to the posted staffing plan. B. Review of the facility’s ABST identified the facility was not consistently updating the ABST per regulation for multiple sampled and unsampled residents. Based on the facility ABST and posted staffing plan, the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents. The need to ensure the facility was staffing sufficient staff per the ABST and posted staffing plan was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator) and Staff 5 (RN) on 01/30/25 at 1:34 pm. They acknowledged the findings. Refer to C 362 and C 363.

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 complete an acuity-based staffing tool (ABST) that accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan for 2 of 2 sampled residents (#s 1 and 2) and failed to develop an accurate staffing plan for each shift, that met the scheduled and unscheduled needs of all residents. Findings include, but are not limited to: 1. Resident 1’s ABST was reviewed during the survey and identified the following: Resident 1’s current ABST, updated on 12/31/24, inaccurately captured care time and care elements that staff were providing in the following care areas: * Bathing; * Transfers; * Supervising, cueing or supporting while eating; * Leisure activities; and * Additional care services, such as smoking assistance or pet care. The need to ensure the facility's ABST accurately captured care time and care elements that staff were providing to the resident was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator) on 01/29/25 at 1:35 pm. They acknowledged the findings. 2. Resident 2’s quarterly ABST, updated on 12/31/24, inaccurately captured care time and care elements that staff were providing. The ABST care time for the following evaluated care elements had zero minutes assigned: * Safety checks and fall prevention; * Communication; * Monitoring behavior conditions and symptoms; * Non-drug interventions for behaviors; * Ambulation including escorts to meals and activities; * Bowel and bladder management including toileting; and * Housekeeping. On 01/30/25 at 1:34 pm, Staff 1 (Administrator) reported she was responsible for updating the facility’s ABST. Staff 1 acknowledged the multiple updates made on 12/31/24 and Resident 2’s ABST was not accurate per evaluated care elements; therefore, the tool did not accurately determine the correct amount of staff time required to provide care to the resident and could not meet the scheduled and unscheduled needs of the residents. The need to ensure the facility's ABST accurately captured care time and care elements that staff were providing to each resident and was used to develop an accurate staffing plan to meet the 24-hour scheduled and unscheduled needs of the residents was discussed with Staff 1, Staff 2 (Assistant Administrator) and Staff 5 (RN) on 01/30/25 at 2:40 pm. They acknowledged the findings.

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

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to update and review the acuity-based staffing tool (ABST) no less than quarterly at the same time the resident’s service plan was updated for multiple unsampled residents and following a significant change of condition for 1 of 2 sampled residents (#1) who had a significant change of condition. Findings include, but are not limited to: The facility’s ABST was reviewed on 01/27/25 at 10:30 am and the following was identified: a. 10 unsampled residents’ ABSTs were updated on 12/31/24 without making resident-specific updates and were not updated to correspond at minimum with the residents’ quarterly service plan update. b. Review of Resident 1’s ABST and clinical records during the survey showed the following: * The resident experienced a significant change of condition following a fall and was diagnosed with a lower back fracture on 01/13/25; and * The resident’s ABST was not updated after the resident’s significant change of condition. On 01/30/25 at 10:25 am, Staff 2 (Assistant Administrator) confirmed the resident’s ABST was not updated following the significant change of condition. The need to ensure residents' ABSTs were updated at required intervals including with significant changes of condition was discussed with Staff 1 (Administrator) and Staff 2 on 01/30/25 5:05 pm. They acknowledged the findings.

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

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 7, 8, 11 and 15) completed pre-service orientation training in all required areas prior to performing their job duties. Findings include, but are not limited to: Staff training records were reviewed with Staff 2 (Assistant Administrator) on 01/30/25. The following was identified: a. Staff 7 (Dietary Aide), hired on 10/15/24, Staff 8 (Resident Aide), hired on 08/09/24, and Staff 15 (Resident Aide), hired on 11/11/24, lacked documented evidence of completing pre-service orientation in fire safety and emergency procedures prior to beginning job duties. b. Staff 11 (Resident Aide), hired on 12/12/24, lacked documented evidence of completing the following required elements of pre-service orientation training prior to beginning job duties: * Fire safety and emergency procedures; * Infectious disease prevention; * Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to behaviors including reducing the use of antipsychotics; * Strategies for addressing social needs & engaging them in meaningful activities; and * Specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach. The need to ensure newly hired staff completed pre-service orientation training in all required areas prior to performing their job duties was reviewed with Staff 1 (Administrator), Staff 2, and Staff 5 (RN) on 01/30/25 at 5:05 pm. They acknowledged these findings.

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

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 8, 11 and 15), demonstrated knowledge and performance in all required areas within 30 days of hire. Findings included but are not limited to: Staff training records were reviewed on 01/30/25 with Staff 2 (Assistant Administrator). The following was identified: a. Staff 8 (Resident Aide) hired on 08/09/24, lacked documented evidence competency was demonstrated in the following areas: * General food safety, serving and sanitation; and * Abdominal Thrust. b. Staff 11 (Resident Aide) hired on 12/12/24, lacked documented evidence competency was demonstrated in the following areas: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting changes of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; and * Abdominal Thrust. c. Staff 15 (Resident Aide) hired on 11/11/24, lacked documented evidence competency was demonstrated in the following areas: * Changes associated with normal aging; * Identification, documentation and reporting changes of condition; * Conditions that require assessment, treatment, observation and reporting; and * Abdominal Thrust. The need to ensure newly hired staff demonstrated competency in all required areas within 30 days of hire was reviewed with Staff 1 (Administrator), Staff 2, and Staff 5 (RN) on 01/30/25 at 5:05 pm. They acknowledged these findings.

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

OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff (6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF. (a) Annual infectious disease training requires the following: (A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training. (B) Annual in-service training must be documented in the employee record. (b) Biennial LGBTQIA2S+ training requires the following: (A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff. (i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite. (ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. (vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state. (D) The proposal for training submitted by a facility, entity, or individual shall include: (i) The regulatory criteria described in paragraph (C) of this section as part of the proposal. (ii) The following elements must be included in the proposal: (I) A statement of the qualifications and training experience of the facility, individual or entity providing the training; (II) The proposed methodology for providing the training either online or in person. (III) An outline of the training. (IV) Copies of the materials to be used in the training. (iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision. (c) Annual Home and Community-Based Services (HCBS) training requires the following: (A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations. (B) Annual in-service training must be documented in the employee record. (C) These annual trainings will be required as of April 1, 2025. (7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF. (a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire. (b) Requirements for annual in-service dementia training: (A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care. (B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter. (C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above. (D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia. (E) The facility shall determine the competency of direct care staff in dementia care in the following ways: (i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19). (ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff. (iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency. (8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process. 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 long-term direct care staff (#s 9 and 10) completed a minimum of 12 hours of in-service training annually, including at least six hours of dementia care training based on their anniversary date of hire, and failed to ensure 1 of 2 long-term non-direct care staff (#17) completed infectious disease prevention training annually. Findings include, but are not limited to: Staff training records were reviewed with Staff 2 (Assistant Administrator) on 01/30/25. The following was identified: There was no documented evidence Staff 9 (Resident Aide), hired 11/11/12 and Staff 10 (CG), hired 05/17/22, completed at least 12 hours of training based on their anniversary dates of hire related to the provision of care in CBC setting and including a minimum of six hours of training on dementia care topics. There was no documented evidence Staff 17 (Receptionist), hired on 11/10/22, completed annual training on infectious disease outbreak and control based on the annual date of hire. The need to ensure long-term direct care staff completed 12 hours of annual in-service training including at least six hours of dementia care training based on their anniversary date of hire and long-term non-care staff completed annual infectious disease training was discussed with Staff 1 (Administrator), Staff 2, and Staff 5 (RN) on 01/30/25 at 5:05 pm. They acknowledged the findings.

OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff (6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF. (a) Annual infectious disease training requires the following: (A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training. (B) Annual in-service training must be documented in the employee record. (b) Biennial LGBTQIA2S+ training requires the following: (A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff. (i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite. (ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. (vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state. (D) The proposal for training submitted by a facility, entity, or individual shall include: (i) The regulatory criteria described in paragraph (C) of this section as part of the proposal. (ii) The following elements must be included in the proposal: (I) A statement of the qualifications and training experience of the facility, individual or entity providing the training; (II) The proposed methodology for providing the training either online or in person. (III) An outline of the training. (IV) Copies of the materials to be used in the training. (iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision. (c) Annual Home and Community-Based Services (HCBS) training requires the following: (A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations. (B) Annual in-service training must be documented in the employee record. (C) These annual trainings will be required as of April 1, 2025. (7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF. (a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire. (b) Requirements for annual in-service dementia training: (A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care. (B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter. (C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above. (D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia. (E) The facility shall determine the competency of direct care staff in dementia care in the following ways: (i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19). (ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff. (iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency. (8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process. 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 (OFC) and fire and life safety instruction was provided to staff on alternate months from fire drills. Findings include, but are not limited to: Six months of facility fire drill and fire and life safety records from 07/2024 to 12/2024 were reviewed on 01/29/25 and revealed the following: a. Fire drills lacked documentation of the escape route used. b. Staff 1 (Administrator) confirmed at 3:15 pm on 01/30/25 there was no documented evidence staff were trained in fire and life safety procedures on alternate months from fire drills. The need to ensure fire drills were conducted per OFC and staff were trained in fire and life safety procedures on alternate months from fire drills was discussed with Staff 1 and Staff 2 (Assistant Administrator), and Staff 5 (RN) on 01/30/25 at 5:05 pm. They acknowledged the findings.

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

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents were instructed in fire and life safety procedures within 24 hours of admission and at least annually thereafter. Findings include, but are not limited to: Facility fire and life safety records were reviewed on 01/29/25 and 01/30/25. The facility lacked documented evidence residents were instructed in general safety procedures, evacuation methods, and responsibilities within 24 hours of admission and annually. The need to ensure residents were instructed in fire and life safety procedures within 24 hours of admission and re-instructed, at least annually, was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), and Staff 5 (RN) on 01/30/25 at 5:05 pm. They acknowledged the findings.

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 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the general exterior of the building was maintained in good repair, measures were taken to prevent the entry of rodents and insects, and the outdoor perimeter fencing was not secured to prevent exit. Findings include, but are not limited to: The exterior of the facility was toured on 01/27/25 and 01/28/25. The following was identified: The concrete pathways of the side patio had areas covered with tree debris creating a possible tripping hazard for residents. Cigarette butts and other garbage littered the front walkway, walkways of the smoking area and exterior yard of the facility. Screens were missing or in disrepair on the windows of unit six, staff bathroom, Administrator’s office and common use areas. The facility had a chain-link fencing and gates that enclosed the property. The gates to these areas were locked with pad locks which would prevent building occupants from exiting in the event of a fire or other emergency. Follow-up observations made on 01/29/25 found the pad locks were removed from the perimeter fencing. The exterior areas of the facility were reviewed with Staff 1 (Administrator) on 01/29/25 at 4:00 pm. She acknowledged the findings regarding the exterior of the facility including the pad locks on the perimeter fencing.

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by:

OAR 411-054-0200 (4)(c) Floors (c) FLOORS. (A) Hard surface floors and base must be free from cracks and breaks. (B) Carpeting and other floor materials must be constructed and installed to minimize resistance for passage of wheelchairs and other ambulation aids. (C) Thresholds and floor junctures must be maintained to allow for the passage of wheelchairs and to prevent a tripping hazard. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure thresholds and floor junctures were maintained to allow for the passage of wheelchairs and to prevent a tripping hazard. Findings include, but are not limited to: Observations made during the survey between 01/27/25 and 01/30/25 revealed the following: The threshold and floor juncture in front of the kitchen door was observed to present a potential tripping hazard; and On 01/28/25 between 2:40 pm – 2:52 pm, an unsampled resident was observed self-propelling a manual wheelchair with his/her feet throughout the facility. The resident had visible difficulty maneuvering over the thresholds from his/her unit into the common area hallway, near the medication room and between the east exit door and the patio area. The resident was observed to need several minutes to maneuver himself/herself over the threshold from his/her unit to the common area hallway and required staff assistance to maneuver over the thresholds near the medication room and the east exit door. A surveyor toured the environment with Staff 1 (Administrator) on 01/30/25 at 5:42 pm. She acknowledged the findings and stated the facility would replace the identified thresholds.

OAR 411-054-0200 (4)(c) Floors (c) FLOORS. (A) Hard surface floors and base must be free from cracks and breaks. (B) Carpeting and other floor materials must be constructed and installed to minimize resistance for passage of wheelchairs and other ambulation aids. (C) Thresholds and floor junctures must be maintained to allow for the passage of wheelchairs and to prevent a tripping hazard. This Rule is not met as evidenced by:

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: The facility was toured on 01/28/25 to 01/29/25, and the following was identified: a. Interior cleaning and repair was needed in the following areas: * Multiple doors, doorframes, baseboards and walls throughout the facility had chipped paint, scrapes, scuffs and black and brown smudges; * Windows, window frames and windowsills throughout the facility had cracks, gouges, debris and buildup of brown debris; * The community bathroom labeled "Resident Bathroom #2" had cracked tiles in the shower; * The community bathroom labeled "Resident Bathroom #3" had floor tiles with a buildup of black and brown matter; * Ceiling above the water fountain and the resident phone (located in hallway next to community water fountain by Room 18) had cracked drywall and was uncleanable; * Privacy screen next to the resident phone located in the hallway next to the community water fountain by Room 18 had stains on the surface; * Ceiling fan near Room 15 had brown debris on its surface; * The seating area to the left of the main entrance had multiple chairs with torn vinyl and were uncleanable, and multiple ceiling tiles had cracks, holes and stains on their surfaces; and * There was a pervasive odor in the hallway outside of Room 6 throughout the survey. b. Exterior cleaning and repair was needed in the following areas: * Multiple areas on the building exterior had black smudges, chipped or flaking paint and gouges; * There were multiple wooden boards strewn on the ground in the side yard; and * Multiple chairs on the outdoor patio had torn vinyl and were uncleanable. During a facility tour on 01/29/25 at 4:00 pm, the need to ensure the interior and exterior of the facility were kept clean and in good repair was discussed with Staff 1 (Administrator). She acknowledged these findings.

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

OAR 411-054-0200 (5) Resident Units (5) RESIDENT UNITS. Resident units may be limited to a bedroom only, with bathroom facilities centrally located off common corridors. Each resident unit shall be limited to not more than two residents.(a) Resident units must have a lockable door with lever type handles, effective 01/15/2017. This applies to all existing and new construction.(b) For bedroom units, the door must open to an indoor, temperature controlled common-use area or common corridor. Residents may not enter a room through another resident's bedroom.(c) Resident units must include a minimum of 80 square feet per resident, exclusive of closets, vestibules, and bathroom facilities and allow for a minimum of three feet between beds;(d) All resident bedrooms must be accessible for individuals with disabilities and meet the requirements of the building codes. Adaptable units are not acceptable.(e) A lockable storage space (e.g., drawer, cabinet, or closet) must be provided for the safekeeping of a resident's small valuable items and funds. Both the administrator and resident may have keys.(f) WARDROBE CLOSET. A separate wardrobe closet must be provided for each resident's clothing and personal belongings. Resident wardrobe and storage space must total a minimum volume of 64 cubic feet for each resident. The rod must be adjustable for height or fixed for reach ranges per building codes. In calculating useable space closet height may not exceed eight feet and a depth of two feet.(g) WINDOWS.(A) Each sleeping and living unit must have an exterior window that has an area at least one-tenth of the floor area of the room. A CF must have at least one exterior window with a minimum size of 8 square feet per resident.(B) Unit windows must be equipped with curtains or blinds for privacy and control of sunlight.(C) Operable windows must be designed to prevent accidental falls when sill heights are lower than 36 inches and above the first floor.(h) RESIDENT UNIT BATHROOMS. If resident bathrooms are provided within a resident unit, the bathroom must be a separate room and include a toilet, hand wash sink, mirror, towel bar, and storage for toiletry items. The bathrooms must be accessible for individuals who use wheelchairs.(i) UNIT KITCHENS. If cooking facilities are provided in resident units, cooking appliances must be readily removable or disconnect-able and the RCF must have and carry out a written safety policy regarding resident-use and nonuse. A microwave is considered a cooking appliance. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to provide lockable doors for 2 of 2 unsampled resident units. Findings include, but are not limited to: An environmental tour was conducted during the survey between 01/27/25 and 01/30/25. On 01/28/25, the surveyor observed resident units 12 A and 14 A without lockable doors. During an interview with Staff 1 (Administrator) on 01/29/25 at 3:17 pm, she acknowledged the findings and noted the facility would relocate the resident in unit 12 A to another unit with a lockable door. Staff 1 stated the facility planned to install a new lockable door for unit 14 A. On 01/30/25 at 10:17 am, follow-up observations of unit 12 A found the unit was no longer occupied. On 01/30/25 at 5:05 pm, the need to ensure the facility provided lockable doors for each resident unit was discussed with Staff 1. She acknowledged the findings.

OAR 411-054-0200 (5) Resident Units (5) RESIDENT UNITS. Resident units may be limited to a bedroom only, with bathroom facilities centrally located off common corridors. Each resident unit shall be limited to not more than two residents.(a) Resident units must have a lockable door with lever type handles, effective 01/15/2017. This applies to all existing and new construction.(b) For bedroom units, the door must open to an indoor, temperature controlled common-use area or common corridor. Residents may not enter a room through another resident's bedroom.(c) Resident units must include a minimum of 80 square feet per resident, exclusive of closets, vestibules, and bathroom facilities and allow for a minimum of three feet between beds;(d) All resident bedrooms must be accessible for individuals with disabilities and meet the requirements of the building codes. Adaptable units are not acceptable.(e) A lockable storage space (e.g., drawer, cabinet, or closet) must be provided for the safekeeping of a resident's small valuable items and funds. Both the administrator and resident may have keys.(f) WARDROBE CLOSET. A separate wardrobe closet must be provided for each resident's clothing and personal belongings. Resident wardrobe and storage space must total a minimum volume of 64 cubic feet for each resident. The rod must be adjustable for height or fixed for reach ranges per building codes. In calculating useable space closet height may not exceed eight feet and a depth of two feet.(g) WINDOWS.(A) Each sleeping and living unit must have an exterior window that has an area at least one-tenth of the floor area of the room. A CF must have at least one exterior window with a minimum size of 8 square feet per resident.(B) Unit windows must be equipped with curtains or blinds for privacy and control of sunlight.(C) Operable windows must be designed to prevent accidental falls when sill heights are lower than 36 inches and above the first floor.(h) RESIDENT UNIT BATHROOMS. If resident bathrooms are provided within a resident unit, the bathroom must be a separate room and include a toilet, hand wash sink, mirror, towel bar, and storage for toiletry items. The bathrooms must be accessible for individuals who use wheelchairs.(i) UNIT KITCHENS. If cooking facilities are provided in resident units, cooking appliances must be readily removable or disconnect-able and the RCF must have and carry out a written safety policy regarding resident-use and nonuse. A microwave is considered a cooking appliance. This Rule is not met as evidenced by:

OAR 411-054-0200 (6)(c-e) Common Use Areas: Social (c) DINING AREA. The dining area must be provided with the capacity to seat 100 percent of the residents. The dining area must provide a minimum of 22 square feet per resident for seating, exclusive of serving carts and other equipment or items that take up space in the dining area. A RCF must have policies and equipment to assure food is served fresh and at proper temperatures. If a CF provides a minimum of 30 square feet per resident for a combined dining, activities, and living area, the CF may apply for an exception to this subsection. (d) SOCIAL AND RECREATION AREAS. A RCF must include lounge and activity areas for social and recreational use totaling a minimum of 15 square feet per resident. If a CF provides a minimum of 30 square feet per resident for a combined dining, activities, and living area, the CF may apply for an exception to this subsection. (e) COOKING STOVE. If a stove is provided in the activities or common-use area, and is available for resident-use, a keyed, remote switch, or other safety device must be provided to ensure staff control. This Rule is not met as evidenced by: Based on observation and interview it was determined the facility failed to ensure the dining area provided a minimum of 22 square feet per resident. Findings include, but are not limited to: During the survey between 01/27/25 and 01/30/25, the capacity for the facility was 46 residents with a current census of 32 residents. The facility had a combined dining and activity area that included six tables with 14 chairs. On 01/30/25 at 2:23 pm, Staff 4 (Maintenance Tech) was asked to provide the square footage of the dining room/activity area. Staff 4 replied he was unaware of the square footage and was observed measuring the room. The room measured at 400 square feet, exclusive of serving carts and other equipment or items that took up space in the dining area. The facility failed to provide a minimum of 22 square feet per resident for seating in the dining area. During an interview with Staff 1 (Administrator) on 01/30/25 at 3:20 pm, she stated “I was unaware of the regulation”. The need to provide a dining area with a minimum of 22 square feet per resident for seating in the dining area was discussed with Staff 1 on 01/30/25 at 3:20 pm. She acknowledged the findings.

OAR 411-054-0200 (8) Heating and Ventilation (8) HEATING AND VENTILATION SYSTEMS. A RCF must have heating and ventilation systems that comply with the building codes in effect at the time of facility construction. (a) TEMPERATURE. For all areas occupied by residents, design temperature for construction must be 75 degrees Fahrenheit. (A) A RCF must provide heating systems capable of maintaining 70 degrees Fahrenheit in resident areas. Required minimum temperatures are no less than 70 degrees Fahrenheit during the day and 60 degrees Fahrenheit during sleeping hours. (B) During times of extreme summer heat, fans must be made available when air conditioning is not provided. (b) EXHAUST SYSTEMS. All toilet and shower rooms must be equipped with a mechanical exhaust fan or central exhaust system that discharges to the outside. (c) FIREPLACES, FURNACES, WOODSTOVES, AND BOILERS. Where used, installation must meet standards of the building codes in effect at the time of construction. The glass and area surrounding the fireplace must not exceed 120 degrees Fahrenheit. (d) WALL HEATERS. Covers, grates, or screens of wall heaters and associated heating elements may not exceed 120 degrees Fahrenheit when they are installed in locations that are subject to incidental contact by people or with combustible material. Effective 01/15/2015, wall heaters are not acceptable in new construction or remodeling. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit when installed in locations that were subject to incidental contact by people. Findings include, but are not limited to: The facility was toured on 01/30/25 and the following was identified: At 01/30/25 at 11:15 am and 12:31 pm, the outer surfaces of the portable, radiator style electric heater in room 18 and the cadet recessed electric heater in the Administrator/RN office were measured with the surveyor's digital thermometer. The outer surface temperature of both heaters exceeded 120 degrees Fahrenheit. The heaters were located where people could come into incidental contact. Staff 1 (Administrator) was observed removing the portable heater from room 18 at 11:25 am. The need to ensure wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit when installed in locations that were subject to incidental contact by people was discussed with Staff 1 on 01/30/25 at 5:05 pm. She acknowledged the findings.

OAR 411-054-0200 (8) Heating and Ventilation (8) HEATING AND VENTILATION SYSTEMS. A RCF must have heating and ventilation systems that comply with the building codes in effect at the time of facility construction. (a) TEMPERATURE. For all areas occupied by residents, design temperature for construction must be 75 degrees Fahrenheit. (A) A RCF must provide heating systems capable of maintaining 70 degrees Fahrenheit in resident areas. Required minimum temperatures are no less than 70 degrees Fahrenheit during the day and 60 degrees Fahrenheit during sleeping hours. (B) During times of extreme summer heat, fans must be made available when air conditioning is not provided. (b) EXHAUST SYSTEMS. All toilet and shower rooms must be equipped with a mechanical exhaust fan or central exhaust system that discharges to the outside. (c) FIREPLACES, FURNACES, WOODSTOVES, AND BOILERS. Where used, installation must meet standards of the building codes in effect at the time of construction. The glass and area surrounding the fireplace must not exceed 120 degrees Fahrenheit. (d) WALL HEATERS. Covers, grates, or screens of wall heaters and associated heating elements may not exceed 120 degrees Fahrenheit when they are installed in locations that are subject to incidental contact by people or with combustible material. Effective 01/15/2015, wall heaters are not acceptable in new construction or remodeling. This Rule is not met as evidenced by:

OAR411-004-0020(2)(b) Physical Setting: Individual Accessible (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (b) The setting is physically accessible to an individual. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the setting was physically accessible to individuals. Findings include, but are not limited to: Observations made during the survey between 01/27/25 and 01/30/25 revealed multiple floor thresholds were difficult for an unsampled resident to maneuver independently. The need to ensure the facility was physically accessible to individuals was discussed and the facility was toured with Staff 1 (Administrator) on 01/30/25 at 5:05 pm. She acknowledged the findings. Refer to C512.

OAR411-004-0020(2)(b) Physical Setting: Individual Accessible (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (b) The setting is physically accessible to an individual. This Rule is not met as evidenced by:

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure each resident unit had a lockable door for residents. Findings include, but are not limited to: Observations made during the survey between 01/27/25 and 01/30/25 found resident units 12 A and 14 A without lockable doors. The handles to the doors lacked locking mechanisms. The need to ensure resident units had a lockable door was discussed with Staff 1 (Administrator) on 01/30/25 at 5:05 pm. She acknowledged the findings. Refer to C515.

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