Print Inspection: RL008156

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 provided clear direction to staff regarding the delivery of services for 3 of 4 sampled residents (#s 2, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 08/2021 with diagnoses including severe malnutrition, difficulty with walking, depression, and alcohol abuse. S/he was subsequently admitted to hospice on 11/11/25, with admitting diagnosis of right upper limb cancer with metastases. Observations were made of the resident's care on 12/03/25. Interviews with the resident, facility staff, and the resident’s outside provider were conducted. The service plan, updated on 11/11/25, was reviewed. Resident 2's service plan lacked clear instruction to staff in the following areas: * Number of staff needed to assist with activities of daily living; * Physician Orders for Life Sustaining Treatment status; * Instructions on specific changes of condition to report to hospice; * Instructions on how to elevate the head of the bed to improve breathing; * Oxygen equipment precautions, instructions for proper maintenance, and how to monitor for safety; * Instructions on what types of skin impairments to report and to whom; * Instructions on to whom to report weight gain or loss and changes in appetite; * Instructions on meal intake monitoring; * How a person expresses memory loss; and * Instructions for aspiration precautions and interventions while choking. The need to ensure service plans provided clear instructions to staff regarding the delivery of services was discussed with Staff 1 (ED), Staff 2 (Assistant ED), Staff 3 (RN), Staff 9 (Regional Director of Operations), and Staff 10 (Regional Director of Operations) on 12/04/25 at 11:48 am. They acknowledged the findings. 2. Resident 3 moved into the facility in 12/2021 with diagnoses including dementia, chronic obstructive pulmonary disease with exacerbation, and depression. The resident’s service plan, dated 11/29/25, was reviewed, and staff were interviewed. The service plan lacked clear direction regarding the delivery of services in the following areas: * Incontinence care, including brief changes performed in bed, frequency staff should check for incontinence, and supplies used; * Bed bath instruction; and * 1:1 activity instruction, frequency, and who should provide the activity. The need to ensure the resident’s service plan provided clear direction regarding the delivery of services was discussed with Staff 1 (ED), Staff 2 (Assistant ED), Staff 3 (RN), Staff 9 (Regional Director of Operations), and Staff 10 (RN Consultant) on 12/04/25 at 1:24 pm. They acknowledged the findings. 3. Resident 4 moved into the facility in 09/2025 with diagnoses including anxiety. The resident’s service plan, dated 09/22/25, was reviewed, and staff were interviewed. The service plan lacked clear direction regarding the delivery of services in the following areas: * Bladder and bowel continence; * Transfer assistance, including the use of a front wheeled walker and gait belt versus using the power wheelchair; * The use of briefs and incontinence pads during the night; * Preference of staff standing by when the resident is in the bathroom; * Preference of minimal disturbance from staff; * Resident 4's morning routine; and * The number of staff needed to evacuate the resident if the elevator was not functioning. The need to ensure the resident’s service plan provided clear direction regarding the delivery of services was discussed with Staff 1 (ED), Staff 2 (Assistant ED), Staff 3 (RN), and Staff 10 (RN Consultant) on 12/04/25 at 9:32 am. They acknowledged the findings.

1) Resident 2, 3 and 4 service plans were reviewed and updated on 12/4/2025 2) Completed an in-service with the service planning team to review the OAR's as they pertain to service planning to address updates, ensuring they are reflected of resident needs and preferences and provide clear direction to staff. 3) IDT will audit 2 random service plans weekly for accuracy and current person centered care needs for 8 weeks then quarterly thereafter, 4) RCC, RN DHS and Executive Director responsible

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 411-054-0055 (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 observation, interview, and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 1 of 1 sampled resident (# 3) who required an altered diet texture. Findings include, but are not limited to: Resident 3 moved into the community in 12/2021 with diagnoses including dementia. During the acuity interview on 12/01/25, the resident was identified to receive a mechanical soft textured diet. The resident’s record was reviewed, including current, signed provider's orders. Observations were made, and interviews with staff were conducted. The following was identified: Resident 3 had a signed physician order for a “Mechanical Soft texture” diet, which pertained to all meals and snacks the facility prepared and served the resident. On 12/03/25 at 9:31 am, Staff 12 (Staffing Coordinator) provided Resident 3 half of a ham and cheese sandwich which was not observed to be prepared as mechanical soft. The resident was observed to consume the half sandwich. S/he cleared his/her throat and coughed multiple times. Staff 12 reminded Resident 3 to eat slowly. During the observation, Staff 12 reported the resident was to receive meals cut into small pieces. On 12/03/25 at 10:51 am, Staff 8 (Dietary Manager) reviewed Resident 3's meal order ticket which had both "mechanical soft" and "chopped" highlighted, which indicated the texture of the meal provided. Staff 8 reported he was unsure which texture the resident received or had a physician’s order for. On 12/03/25 at 12:15 pm, the resident was observed eating a cut-up turkey burger on a bun which was not prepared as mechanical soft. On 12/04/25 at 10:45 am, Staff 11 (LPN) confirmed the resident was on a mechanical soft diet. The need to ensure the facility followed prescriber’s orders related to diet texture was reviewed with Staff 1 (ED), Staff 2 (Assistant ED), Staff 3 (RN), Staff 9 (Regional Director of Operations), and Staff 10 (RN Consultant) on 12/04/25 at 1:24 pm. They acknowledged the findings.

1) Dietary Manager was immediately in-serviced on dietary textures and resident orders to ensure accuracy. All dietary staff and staff delivering meals will be in-serviced on diet textures and the importance of following physician orders on 12/29/2025. 2) Modified diets will be monitored through direct meal observations by Dietary Manager, Executive Director or designee. 3) Observations will occur daily for 2 weeks, then weekly for 4 weeks and random observations there after 4)Dietary Manager, Executive Director, Assistant Executive Director

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: