Print Inspection: RL003574

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: ?Based on interview and record review, it was determined the facility failed to ensure residents were evaluated, referred to the facility nurse, changes were documented, and the service plan was updated for 1 of 1 sampled resident (#2) who experienced a significant weight gain, and failed to ensure actions or interventions were determined, documented, communicated to staff on each shift and weekly progress was noted to resolution for 2 of 3 sampled residents (#s 1 and 3) who experienced short-term changes of condition. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 11/2015 with diagnoses including inappropriate antidiuretic hormone secretion (a condition that causes water retention). The resident’s progress notes and service plan addendums dated 01/01/25 to 03/31/25, service plan dated 03/13/25, 03/01/25 to 03/31/25 MAR, and six months of weights were reviewed. The following was identified: Resident 2’s recorded weights were as follows: * 02/15/25 – 113.7 pounds; * 03/09/25 – 115.8 pounds; * 03/11/25 – 131.8 pounds; * 03/15/25 – 131.7 pounds; and * 04/01/25 – 127 pounds (taken during survey). From 03/09/25 to 03/11/25, the resident gained 16 pounds or 13.8% of his/her bodyweight, which was a significant change of condition. Subsequent weights confirmed the significant weight gain, which required the facility to evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. There was no documented evidence the above was completed. At 12:32 pm on 04/01/25, Staff 3 (Director of Nursing Services) stated she had not been notified of the significant weight gain. The need to ensure significant changes of condition were referred to the facility nurse, evaluated, documented, and the service plan was updated as needed was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Manager) on 04/02/25. They acknowledged the findings, and no further information was provided. ?2. Resident 3 was admitted to the facility in 01/2019 with diagnoses including schizophrenia. The resident's 01/01/25 through 03/30/25 progress notes, 03/13/25 service plan, evaluations, incident reports, and service plan addendums were reviewed. The following changes of condition were identified: * An addendum to service plan, dated 03/21/25, indicated post surgical instructions which included “Staff will need to monitor [his/her] incision sight on [his/her] head.” There was no documented evidence the facility monitored the resident at least weekly to resolution. The need to ensure short-term changes of condition was monitored at least weekly to resolution was discussed with Staff 1 (Administrator), Staff 3. Resident 1 was admitted to the facility in 03/2023 with diagnoses including anxiety due to PTSD. A review of the resident's clinical records dated 01/01/25 through 03/31/25 indicated the following changes of condition: * 02/14/25 – Resident returned from emergency room visit; * 03/05/25 - Resident had a non-injury fall; * 03/24/25 – RN/LPN noted “bruise above left eyebrow”’ and * Resident experienced nine non-injury falls between 01/05/25 and 03/26/25. There was no documented evidence the facility had evaluated these changes to determine actions and interventions or provided written instructions to staff related to fall interventions. The need to ensure resident-specific instructions or interventions were developed, implemented, and reviewed for effectiveness were discussed with Staff 1 (Administrator), Staff 2 (Resident Care Manager), and Staff 3 (Director of Nursing) on 04/02/25 at 12:30 pm. They acknowledged the findings. A new fall evaluation form was provided to survey team on 04/02/25 at 1:45 pm.

1a. MatrixCare parameters were adjusted to trigger alerts for nursing staff when vital signs indicate a short-term or significant change in condition, in alignment with regulatory guidelines. All residents vitals were reviewed and any short-term/significant changes were implemented. 1b. Incision was followed up on and a new Significant Change form was developed to outline required documentation and follow-up actions, ensuring compliance and continuity of care. 1c. Resident’s fall interventions reviewed, additional interventions implemented. A revised Fall Assessment form has been implemented to include detailed documentation of interventions performed. Additionally, the Physical Incident Report has been updated to reflect fall-related interventions and post-fall follow-up measures. 2a. MatrixCare parameters were adjusted to generate automatic alerts for nursing staff when vital signs indicate a short-term or significant change in condition. This ensures timely identification and response to changes, aligning with regulatory expectations. 2b. A standardized Significant Change form was created to ensure all required documentation and follow-up actions are completed. This form functions as a checklist, helping staff meet all regulatory requirements consistently. 2c. A new Fall Assessment form was implemented to document interventions performed after a fall. Additionally, the Physical Incident Report was updated to include fall-related interventions and required follow-up actions to ensure thorough and timely response to all fall events. 3a. Monitoring and documentation will occur on a weekly basis. 3b. Reviews will be conducted at each instance of a significant change and continued on a weekly basis thereafter to ensure appropriate follow-up and resolution. 3c. Physical Incident Reports will be reviewed at the time of each fall, with corresponding fall assessments completed quarterly to evaluate patterns, interventions, and outcomes. 4a. Director of Nursing 4b. Director of Nursing 4c. Administrator & Director of Nursing

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

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: ?Based on interview and record review, it was determined the facility failed to ensure an RN assessment had been completed that included resident status and interventions made as a result of the assessment for 1 of 1 sampled resident (#3) who had a significant weight loss. Findings include, but are not limited to: Resident 3 was admitted to the facility in 01/2019 with diagnoses including schizophrenia. The resident’s 10/20/24 through 01/19/25 facility weight records, 01/01/25 through 03/30/25 progress notes, 03/13/25 service plan, evaluations, interoffice memos, and service plan addendums were reviewed. Interviews with staff were conducted. On 03/21/25 Staff 3 (Director of Nursing Services) completed an RN assessment for a significant change of condition regarding “Res [Resident 3] return from the hospital for SDH [subdural hematoma] after a fall. Has some significant changes.” The RN assessment noted weight loss of “27#’s [pounds]” but no additional information about the resident’s status or interventions related to the weight loss were noted. The most recent facility weight records revealed Resident 3 weighed 223.4 pounds on 01/29/25. On 04/02/25 Staff 3 confirmed Resident 3 was last weighed in the hospital and was “approximately 200 pounds.” Between approximately 01/29/25 and 03/21/25, Resident 3 lost 23.4 pounds, or 10% of his/her total body weight in less than two months, which was considered severe and triggered a significant change of condition. There were no additional weight records to review, and Staff 3 confirmed there was no documented evidence the facility had taken Resident 3’s weight since returning from to the facility. Resident 3 was weighed during survey on 04/01/25 and was 211 pounds. During an interview on 04/01/25 at 1:00 pm, Staff 3 acknowledged Resident 3 had a significant weight loss while in the hospital related to not eating. “[S/he] had childhood trauma and won’t eat around people. I expected that [s/he] would gain weight once [s/he] was back and I would just watch to see if [s/he] was eating.” Staff 3 acknowledged the RN assessment lacked information regarding resident status and interventions. Prior to exit, Staff 3 completed a progress note that included additional information regarding resident status and identified and communicated interventions to staff. The need to ensure an RN assessment was completed which documented resident status and interventions made as a result of the assessment for all significant changes of condition was discussed with Staff 1 (Administrator), Staff 2 (Resident Care Manager) and Staff 3 on 04/02/25 at 1:15 pm. They acknowledged the findings.

1. A new Significant Change form was developed to outline required documentation and follow-up actions, ensuring compliance and continuity of care. 2. A standardized Significant Change form was created to ensure all required documentation and follow-up actions are completed. This form functions as a checklist, helping staff meet all regulatory requirements consistently. 3. Weekly 4. Director of Nursing

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

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: ?Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 2 of 3 sampled residents (#s 2 and 3) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 11/2015 with diagnoses including traumatic brain injury and was identified in the acuity interview as having behaviors. The resident’s 03/01/25 to 03/31/25 MAR, progress notes, and current physician orders were reviewed. The following was identified: The resident had an order for clonazepam 1 mg, give 1 tablet as needed for anxiety prior to medical appointments or procedures. The MAR showed staff administered the medication on 03/08/25 and 03/23/25 for behaviors. At 12:32 pm on 04/01/25, Staff 3 (Director of Nursing Services) confirmed the medication was to be given for anxiety prior to medical appointments and not for behaviors. The need to ensure medication orders were carried out as prescribed was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Manager) on 04/02/25. They acknowledged the findings, and no further information was provided. ?2. Resident 3 was admitted to the facility in 01/2019 with diagnoses including schizophrenia. The resident's 03/01/25 through 03/31/25 MARs, 03/21/25 physician orders and the 03/21/25 After Visit Summary from a hospital discharge were reviewed and noted the following: 1. The MAR showed the resident had an order for oxycodone 5 mg, administer half to 1 tablet every 6 hours PRN for moderate to severe pain. The After Visit Summary noted it was available to be picked up at the hospital pharmacy. On 04/02/25 at 10:10 am the surveyor attempted to review the Substance Distribution log and the oxycodone with Staff 2 (Resident Care Manager). Staff 2 acknowledged the medication was not in the facility. Staff 2 indicated when a medication is filled at the hospital “we have them fax over the prescription to [facility’s] pharmacy or we would send someone over to the hospital to pick it up.” On 04/02/25 at 12:15 pm, Staff 3 (Director of Nursing Services) indicated she requested the medication be delivered urgently. 2. A treatment order for white petroleum ointment was to be applied to a skull incision twice daily for 5 days between 03/21/25 through 03/26/25. The MAR revealed the 8 PM dose was not administered on 03/25/25 and 03/26/26 because “the drug/item was not available.” The treatment was administered at 8:00 am on 03/26/26. On 04/02/25 Staff 2 (Resident Care Manager) acknowledged the same medication was also available in the supply closet. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (Administrator), Staff 2 and Staff 3 on 04/02/25 at 1:15 pm. They acknowledged the findings.

1a. Staff were counseled on the importance of adhering strictly to physician orders. Order wording was revised to clearly indicate the purpose of each medication. During medication ordering and review periods, staff will verify that all medications have been administered in accordance with the updated orders. 1b. Pain med was followed up on to ensure delivery. The Order Double-Check Form was updated to include a specific section confirming whether the medication was received. During each medication order and review, staff will cross-check all physician orders against medications currently in stock to ensure any missing items are promptly followed up on. 1c. Staff were counseled on the proper location and access to over-the-counter medications and supplies. When a treatment is ordered and the medication is available in the supply closet, a portion will be allocated, labeled with the resident’s information, and stored in an easily accessible location to prevent delays or confusion during administration. 2a. Staff were re-educated on the importance of following physician orders exactly as written. To prevent future confusion, medication order wording was revised to clearly state the purpose of each medication. During medication order and review processes, staff will now verify that medications are being administered according to the current order instructions. 2b. The Order Double-Check Form was updated to include a section confirming whether each medication has been received. At each med order and review interval, staff will compare every active order to on-hand medications to ensure all items are available. Any discrepancies will be immediately followed up on and resolved. 2c. Staff received training on the location and proper use of over-the-counter (OTC) medications and treatment supplies. When treatments are ordered and the required items are available on-site, a portion of the supply will be allocated and labeled with the resident’s information. This ensures that items can be quickly located and used as prescribed, preventing delays or missed treatments. 3a. Med order/review will be conducted weekly 3b. The Order Double-Check Form done at each new order & Med order/review will be conducted weekly 3c. Med order/review will be conducted weekly 4a. Resident Care Manager Assistant 4b. Order Double-Check Form to be completed by LN’s & DNS, Med order/review will be conducted by Resident Care Manager Assistant 4c. Resident Care Manager Assistant

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 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by: ?Based on interview and record review, it was determined the facility failed to ensure PRN medications given to treat resident's behavior were used only after non-pharmacological interventions were tried with ineffective results and then documented for 2 of 2 sampled residents (#s 1 and 3) who had PRN psychotropic medications prescribed. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 03/2023 with diagnosis including anxiety due to PTSD. Review of the resident's service plan, physician orders, and 03/01/25 through 03/31/25 MAR revealed the following: Resident 1 was prescribed Quetiapine 25 mg (anti-anxiety medication), administer one tablet three times daily PRN for anxiety. The facility failed to ensure the resident's MAR and clinical record included the following required information: * Non-pharmacological interventions to attempt prior to administration of the medication on seven of the eleven occasions given between 03/04/25 and 03/30/2025. The need to ensure the required information for PRN psychotropic medications was documented in the MAR or clinical record was discussed with Staff 1 (Administrator), Staff 2 (Resident Care Manager), and Staff 3 (Director of Nursing) on 04/02/25 at 12:30 pm. They acknowledged the findings. ?2. Resident 2 moved into the facility in 11/2015 with diagnoses including traumatic brain injury and was identified in the acuity interview as having behaviors. The resident’s 03/01/25 to 03/31/25 MAR and current physician orders were reviewed. The following was identified: The resident had an order for haloperidol lactate 2 mg/ml, administer 1 ml by mouth every 6 hours as needed for agitation. Staff administered the medication on 03/01/25, 03/02/25, 03/03/25, 03/13/25, and 03/30/25. There was no documented evidence non-pharmacological interventions were attempted with ineffective results prior to administering the medication. The need to ensure the required information for PRN psychotropic medications was documented in the MAR or clinical record was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Manager) on 04/02/25. They acknowledged the findings, and no further information was provided.

1. All psychotropic medication orders have been updated to include a reminder for nursing staff to attempt and document all non-pharmaceutical interventions. This update has been reviewed with all nursing staff. 2. A psychotropic medication report will be printed and reviewed regularly. 3. Quarterly 4. Director of Nursing

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. 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 in accordance with the Oregon Fire Code. Findings include, but are not limited to: Fire and life safety records from 11/2024 and 03/2025 were reviewed and showed fire drill documentation was lacking in the following areas: * The escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; * Evacuation time-period needed; and * Evidence of alternate routes used. Additionally, staff interviewed did not know the designated point of safety. The need to ensure all required components were addressed and documented for each fire drill was discussed with Staff 1 (Administrator), Staff 2 (Resident Care Manager) and Staff 3 (Director of Nursing Services) on 04/02/25 at 1:15 pm. The staff acknowledged the findings.

1. The fire drill form was updated to include all previously missing information. The Maintenance Assistant was counseled on the importance of completing all required components during fire drills. Additionally, all staff were retrained on their designated point of safety. 2. Fire drill form updated to include: ? escape routes used ? residents who participate in drills ? evacuation time period ? alternative routes 3. Every other month 4. Maintenance Assistance & Administrator

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: