Print Inspection: RL002683

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 readily available to staff, reflective of residents' current care needs, and service plans provided clear directions to staff regarding the delivery of services for 4 of 6 sampled residents (#s 1, 2, 4 and 6) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 12/2024 with diagnoses including chronic diastolic heart failure and chronic kidney disease. Additionally, the resident’s hospital discharge notes included a diagnosis of type 2 diabetes mellitus, which was not on the facility’s list of primary diagnoses. Observations were made of the resident's care on 02/10/25 and 02/11/25, interviews with the resident and facility staff were conducted, and the service plan dated 01/11/25 was reviewed. The facility completed a service plan dated 02/08/25 following a significant change of condition while the survey team was on site and provided a copy to the surveyor on 02/12/25. Resident 4's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Instructions on signs and symptoms of hypo- and hyperglycemia to report; * Instructions for proper maintenance of blood sugar monitor on right upper extremity and how to monitor for malfunctions; * Instructions to staff on blood glucose monitoring protocol when resident slept late and skipped meals; * Instructions for bleeding precautions and interventions while on anticoagulation therapy (Xarelto); * Recent losses related to separation from a family member; * Instructions for aspiration precautions and interventions while choking; * Incontinence care and maintenance of supplies; * Instructions on what types of skin impairments to report and to whom; * Instructions for signs and symptoms of infection to report while monitoring the wound site; * Number of staff needed to assist with dressing and emergency evacuations; * Incorrect reference to use of transfer pole; * Electric scooter equipment precautions and instructions for proper maintenance; * Instructions on to whom to report weight gain or loss; and * Pharmaceutical interventions for pain, including how the resident expressed pain or discomfort. The facility made service plans available to staff by storing them in a binder located at the staff station on the floor where the resident resided. However, Resident 4’s current service plan was not included in the binder and not available to facility staff at the time of the survey. The need to ensure service plans were readily available to staff, reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 3 (Memory Care Administrator) and Staff 7 (LPN) on 02/12/25 at 3:18 pm. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 11/2023 with diagnoses including anxiety and memory loss. During the survey, the resident was observed to require two staff members to assist with ADL tasks including incontinence care. Observations of the resident, interviews with the staff, and the 01/31/25 service plan was reviewed during the survey. The service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas: * Bathing; * Dressing; * Eating including where resident preferred to dine; * Weight gain and parameters; * Toileting; and * Behaviors including resident specific interventions. The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 3 (Memory Care Administrator) on 02/12/25 at 1:15 pm. She acknowledged the findings. 3. Resident 2 moved into the facility in 09/2023 with diagnoses including frontotemporal brain disease and left femoral neck fracture. During the survey, the resident was observed in a hospital bed with an alternating pressure mattress. The resident required two staff members to assist with ADL tasks, including dressing, incontinence care, and bed mobility. Observations of the resident, interviews with the staff, and the 12/31/24 service plan reviewed during the survey showed the service plan was not reflective and/or lacked resident-specific direction for staff in the following areas: * Number of staff required to assist with ADL tasks, including dressing, meals, bed mobility, toileting, and transfers; * Ambulation ability; * Pain after femoral neck fracture; * Use of fall mat; * Use of a Drive air mattress; * Continence status; and * Instructions on use of Geri chair. The need to ensure the service plan reflected the resident’s current care needs and provided clear instructions for staff was discussed with Staff 3 (Memory Care Administrator) on 02/12/25 at 2:20 pm. She acknowledged the findings. 4. Resident 6 was admitted to the facility in 05/2021 with diagnoses including dementia. During the survey, the resident was observed in a wheelchair, able to self-propel. The resident required staff assistance for transfer, incontinence care and feeding assistance as needed. Observation of the resident, interviews with staff, and the 01/16/25 service plan reviewed during the survey showed the service plan was not reflective and/or lacked resident-specific direction for staff in the following areas: • Conflicting information regarding the resident’s use of a wheelchair and/or walker; • One to two staff member assist with transfer; • Meal assistance; • Use of arm sling status; and • Bathing or shower. The need to ensure the service plan reflected the resident’s current care needs and provided clear instructions for staff was discussed with Staff 3 (Memory Care Administrator) on 02/12/25 at 12:00 pm. The staff acknowledged the findings.

1. Actions; Resident 1, 2, 4 and 6 service plans updated and made available to the staff. Detailed information on signs and symptoms infection to report while monitoring wound site and who to report to added to EMAR (TSPs and alert charting). Audit completed to ensure all current service plans are available for staff. Geri chair assessment completed on 2/26/25. 2.The evaluation for gathering initial resident information has been revised to include number of staff for given ADL or task. The health services director completed re-training with resident care managers on proper service planning. Resident Care Managers will be equipped to create thorough, clear, and comprehensive service plans that address all the needs of each resident and to ensure no critical care information is overlooked or omitted. The service plan will be reviewed for accuracy after the resident care manager makes changes and prior to meeting with resident and/or responsible party. Monthly audit of service plan will be completed by Health Service Director and Memory Care Administrator monthly. Discuss in daily clinical meetings and will track on dashboard. LN will add location, size and infection control information to TSP's and alert charting for all resident wounds. Assessment has been created for Geri chair as a supportive device. 3. Service plans will be reviewed upon initial, 30 day, 90 day and for all change of condition service plans. Audits of caregiver binders completed monthly. Daily communication of service plans posted to staff in clinical meetings. 4. Health Services Director, Memory Care Administrator LN and RN.

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

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to determine and document what actions or interventions were needed for short-term changes of condition, communicated actions and interventions to staff on each shift, and monitored the change of condition at least weekly until resolved for 2 of 6 sampled residents (#s 4 and 5) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 5 moved into the facility in 11/2023 with diagnoses including Sjogren syndrome. The resident's current service plan dated 12/30/24, progress notes dated 11/19/24 through 02/03/25, and interim service plans (ISPs) were reviewed. The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and progress noted at least weekly through resolution: * 12/08/24 - Rectal bleeding; and * 12/15/24 - Medication change. The need to ensure the facility determined and documented what action or interventions were needed for changes of condition, the interventions were communicated to staff on all shifts and were monitored at least weekly through resolution was discussed with Staff 3 (Memory Care Administrator) on 02/12/25. She acknowledged the findings. 2. Resident 4 was admitted to the facility in 12/2024 with diagnoses including chronic diastolic heart failure and chronic kidney disease. Additionally, the resident’s hospital discharge notes included a diagnosis of type 2 diabetes mellitus, which was not on the facility’s list of primary diagnoses. Clinical records, including the current service plan and charting notes from 12/11/24 through 02/10/25 were reviewed, and interviews with the resident and facility staff were conducted. The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved: * 12/13/24 – “Resident is having a difficult time being separated from his/her [family member].”; * 12/13/24 – missed insulin injection administration; * 12/15/24 – order to start tramadol (for pain); * 12/20/24 – order to start gabapentin (for pain); * 01/07/25 – order to start hydrocodone-acetaminophen as needed for pain; * 01/13/25 – “has new bruise of self infected [sic] injury during noc [night] shift.”; * 01/16/25 – returned to the facility following hospitalization for witnessed fall with injuries and a heart failure exacerbation; * 01/22/25 – “had a choking episode…this writer was able to perform abdominal thrust.”; * 01/22/25 – “continued to show difficulty swallowing, unsure if it’s a new behavior.”; * 01/22/25 – order to start Keflex (antibiotic therapy) for infected toe; * 01/23/25 - order to discontinue vitamin D (supplement); * 01/24/25 – order to reduce furosemide (for edema) to 10 mg a day; * 01/28/25 – returned from ER following unwitnessed fall resulted in left eyebrow laceration and multiple skin tears; * 01/29/25 - …s/he “c/o [complains of] constipation. [S/he] is unable to recall the last time [s/he] had a BM [bowel movement].”; * 01/31/25 – “had a significant weight gain in January.”; and * 02/08/25 – returned to the facility following hospitalization for small bowel obstruction with multiple medication changes. The need to ensure the facility evaluated the resident and determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was reviewed with Staff 3 (Memory Care Administrator) and Staff 7 (LPN) on 02/12/25 at 3:18 pm. They acknowledged the findings.

1.Resident 5, 4 TSP’s have added documentation regarding specific actions and interventions needed for each short- term change of conditions. TSP are available through EMAR system to communicate these actions or interventions to staff on all shifts. Weekly charting notes have been documented for residents 4 and 5 both conditions are resolved. 2.Training completed with nurses and resident care managers to review TSP processes to accurately capture any short term change of conditions. 3.TSP's will be reviewed daily during clinical meeting. 4. LN, Health Services Director, Memory Care Administrator and Resident Care Managers.

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 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment for 2 of 2 sampled residents (#s 2 and 6) and multiple unsampled residents for meal service. Findings include, but are not limited to: a. Resident 2 moved into the facility in 09/2023 with diagnoses including frontotemporal brain disease and left femoral neck fracture. At 10:50 am on 02/11/25, Staff 32 (CG) and Staff 38 (CG) were observed providing incontinence care for Resident 2. During the observation, both staff donned gloves without performing hand hygiene, assisted the resident in turning side to side and removed his/her soiled brief. Staff 32 provided perineal care and applied barrier cream. Both staff failed to doff soiled gloves, perform hand hygiene and don clean gloves before touching the resident's body and applying a clean brief, clothing, and new bedding for the resident. b. Observations of meal service were conducted for breakfast meal on 02/11/25 in Devonshire 2. Caregiving staff were observed serving food and feeding residents without wearing a protective covering over potentially contaminated clothing and assisting multiple unsampled residents with meal service without performing hand hygiene or glove changes in between assisting different residents with their meal. The need to maintain effective infection prevention and control protocols was discussed with Staff 3 (Memory Care Administrator) on 02/12/25. The findings were acknowledged. c. Resident 6 was admitted to the facility in 05/2021 with diagnoses including dementia. The surveyor observed on 02/23/25 at 10:10 am, Staff 38 (CG) provided incontinence care for Resident 6. During the observation, Staff 38 donned gloves without performing hand hygiene. Staff 38 then assisted the resident in turning side to side, removed the resident’s soiled brief, wiped and cleaned the resident’s perineum area and touched the resident’s body, clean incontinent product, the resident’s clean clothing and wheelchair while using the soiled gloves. Staff 38 failed to change gloves between clean and dirty tasks and perform hand hygiene prior to donned gloves. The above observation was discussed with Staff 3 (Memory Care Administrator) on 02/12/25 at 12:00 pm. The staff acknowledged the appropriate infection control practices were not implemented.

1. Infection control and hand hygeine and correct use of apron retraining completed for all staff serving meals and providing care. 2.Retraining information added to knowledge base in Connecteams for all team members to access at anytime. Adding meal observation as part of our monthly kitchen audits completed by RCM. Adding Infection control specific to hand hygeine, correct apron use and when to don and doff gloves when providing resident care to our bi-annual skills fair. 3. meal observation will be completed monthly in neighborhoods. Relias preservice and Bi- annual training in skills fair. 4. RCM, Health Service Director, Memory Care Administrator, LN

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by:

OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications were evaluated upon move-in and had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications for 1 of 1 sampled resident (# 4) who was reviewed for self-administration. Findings include, but are not limited to: Resident 4 was admitted to the facility in 12/2024 with diagnoses including chronic diastolic heart failure and chronic kidney disease. Additionally, the resident’s hospital discharge notes included a diagnosis of type 2 diabetes mellitus, which was not on the facility’s list of primary diagnoses. During the acuity interview on 02/10/25, Resident 4 was not identified as self-administering any of his/her medications. Resident 4’s charting notes from 12/11/24 through 02/10/25 and MARs from 12/11/24 through 02/10/25 were reviewed. It was noted s/he was self-administering his/her insulin and Ozempic subcutaneous injections (to control blood glucose level), and Miralax powder (bowel care) medications from the initial admission to the facility until hospitalization on 01/30/25 for a small bowel obstruction. This was confirmed by Staff 6 (LPN) in an interview on 02/10/25 at 12:50 pm and by Resident 4 in an interview on 02/11/25 at 11:07 am. Facility assumed the medication management when Resident 4 was discharged from the hospital on 02/08/25. Review of Resident 4’s medical records revealed there was a physician's or other legally recognized practitioner's written order given at the time of admission to the facility stating, “Patient may self administer over the counter meds if [s/he] choose.” Insulin and Ozempic injections were not over the counter medications. On 02/12/25, Staff 3 (Memory Care Administrator) acknowledged no physician or other legally recognized practitioner’s written order was available for the injections. There was no documented evidence the resident was evaluated upon move-in for his/her ability to safely self-administer medications. The need to ensure residents who chose to self-administer their medications were evaluated upon move-in and had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications was reviewed with Staff 3 and Staff 7 (LPN) on 02/12/25 at 3:18 pm. They acknowledged the findings.

1. Resident 4 self-med assessment has been completed by LN and a reconciliation of current medications was obtained. Orders obtained from primary care indicating medication approved for self-administration. 2. Move in orders obtained prior to admission have been revised to clearly indicate if resident is safe to administer medications and if so which ones. Self-med assessment form will be completed, and resident and/or responsible party may manage medication if they pass the self-med assessment. Residents will be added to Whiteboard in teams to keep track of when the next assessment is due to ensure they are completed on time. 3. This process will be completed at the initial move in or when a resident is requesting to self-administer medications. Audit of the whiteboard will be completed at the beginning of each month by LN 4. LN and Health Service Director

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

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure they accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan for 3 of 6 sampled residents (#s 1, 2, and 6) whose ABST were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 11/2023 with diagnoses including anxiety and memory loss. Observations of the resident, interviews with the resident and staff, the 01/31/25 service plan and Temporary Service Plan (TSPs), from 12/01/24 through 02/10/25, and Resident 1’s ABST data was reviewed. The following areas were not reflective of the resident’s current ADL assistance: * Bathing; * Toileting; * Dressing; * Behavior; and * Behavior Management. The need to ensure the ABST tool addressed the amount of staff time needed to provide care was discussed with Staff 3 (Memory Care Administrator) on 02/12/25 at 1:15 pm. The staff acknowledged the findings. 2. Resident 2 moved into the facility in 09/2023 with diagnoses including frontotemporal brain disease and left femoral neck fracture. Observations of the resident, interviews with the resident’s family and staff, the 12/31/24 service plan, and Temporary Service Plans (TSPs), from 12/16/24 to 02/08/25, and Resident 2’s ABST data was reviewed. The following areas were not reflective of the resident’s current ADL assistance: * Time spent assisting with eating. The need to ensure the ABST tool addressed the amount of staff time needed to provide care was discussed with Staff 3 (Memory Care Administrator) on 02/12/25 at 2:25 pm. She acknowledged the findings. 3. Resident 6 was admitted to the facility in 05/2021 with diagnoses including dementia. During the survey, the resident was observed requiring staff assistance along with multiple prompts or encouragement to initiate and maintain meal intake. At one point, the resident required physical feeding assistance. Observations of the resident, interviews with the resident and staff, the 01/16/25 service plan and Temporary Service Plan (TSPs), from 02/01/25 through 02/10/25, and Resident 6’s ABST data were reviewed. The following areas were not reflective of the residents current ADL assistance: • Time spent cueing or redirecting due to cognitive impairment; and • Time spent assisting with eating. The need to ensure the ABST tool addressed the amount of staff time needed to provide care was discussed with Staff 3 (MC Administrator) on 02/12/25 at 12:00 pm. The staff acknowledged the findings.

1. Resident 1, 2, 6 service plan were corrected to reflect accurate staff time needed for all ADL's including if each ADL's requires 1 or 2 staff members to complete. 2. We adjusted our assessment to include 20 minutes of include acuity for all residents with behavior and redirection needs. We will add additional staff time in our service plans for those residents requiring significant staff time for behaviors and redirecting beyond 20 minutes. ABST is reviewed daily during daily clinical meetings to ensure adequate staffing. 3. This will be reviewed at the time of initial, 30 day, periodic and change of condition service plan reviews. 4. RCM, Memory Care Administrator and Health Services Director.

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

Refer to plan of correction for C362

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

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to ensure health service were consistently provided. Findings include, but are not limited to: Refer to C260, C270, C295 and C325

Refer to plan of correction for C260, C270, C295 and C325

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