Print Inspection: RL009619

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' current care needs, provided clear direction regarding the delivery of services, and were updated following a significant change of condition 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 1 moved into the facility in 10/2025 with diagnoses including chronic obstructive pulmonary disease (COPD) and congestive heart failure. The resident's current service plan, dated 12/10/25, was reviewed and was not reflective of the resident's needs or did not provide clear instruction to staff in the following areas: * Ability to use call system; * Activities; * Transportation assist; * Mail, financial and legal needs assistance; * Ability to use cell phone; * Time spent sleeping; * Side rails on bed, to include monitoring and safety instruction; * Mobility to and from smoking area; * Ability to communicate symptoms of pain and anxiety, and need for PRN medication; * Oxygen use instructions for staff; * Assistance with food and fluids; * Toileting/continence; * Bed bound; * Pain; * Dentures; * Grooming and hygiene assistance; * Glasses; * Cat care; and * Recent loss of spouse. Observations of Resident 1 on 02/23/26 and 02/24/26 revealed the resident was independent with bed mobility, transfers, and ambulation without a device in the apartment, was on continuous oxygen, used a wheelchair with staff assist to go to and from the dining room and outside to smoke, and was independent with eating. The resident was alert, oriented, and able to make his/her needs known. The bed had two one-half length side rails in the up position. Resident 1 reported that he/she wore glasses at times, had an upper denture, and was independent with dressing, grooming, toileting, and hygiene. During an interview on 02/23/26 at 1:15 pm with Staff 4 (RCC), she verified the service plan was not reflective and did not include instruction for staff, stating “the whole service plan needs to be redone.” The need to ensure service plans were reflective of resident needs and provided clear direction to staff was discussed with Staff 1 (ED) on 02/23/26 at 3:15 pm. She acknowledged the findings. The service plan was updated on 02/24/26 by Staff 6 (Regional RN). 2. Resident 3 was admitted to the facility in 10/2025 with diagnoses including Multiple Sclerosis, macular cyst, and migraines. Review of Resident 3's service plan, dated 01/22/26, and interviews with staff and the resident revealed the service plan was not reflective or lacked clear direction to staff in the following areas: * Ambulation status; * Fall interventions; * Home exercise program from Physical Therapy; and * Weight refusals. The service plan included the statement, “[Resident 3] is able to manage ambulation and mobility independently at this time.” In an interview on 02/24/26 at 1:05 pm, Staff 12 (Lead PCA/Med Tech) stated Resident 3 was a “heavy two-person transfer” and “can’t walk at all, even with assistance.” On 02/25/26 at 12:50 pm, the need to ensure service plans were reflective of residents’ current status and provided clear direction to staff was discussed with Staff 1 (ED). She acknowledged the findings. 3. Resident 2 moved into the facility in 07/2024 with diagnoses including stroke resulting in right-sided hemiplegia and hemiparesis of the dominant side, Type 2 diabetes mellitus, and chronic obstructive pulmonary disease. The acuity interview conducted on 02/23/26 identified Resident 2 as requiring a two-person assist for transfers using a Hoyer lift and assistance with ADLs. Review of progress notes, dated 11/23/25 through 02/23/26, indicated Resident 2 was hospitalized on 12/10/25 and subsequently transferred to a skilled nursing facility, remaining out of the facility for 37 days. Record review indicated the facility RN completed a significant change of condition “evaluation/assessment” on 01/14/26 while the resident was at the skilled nursing facility and prior to the resident’s return to the facility. The significant change of condition “evaluation/assessment” identified increased care needs requiring two-person assistance with a Hoyer lift for transfers and ADLs and documented a diagnosis of osteomyelitis treated with long-term use of antibiotics at the skilled nursing facility. Resident 2 returned to the facility on 01/16/26. There was no documented evidence the resident’s service plan was reviewed and updated to reflect the significant change of condition, including increased transfer assistance and medical needs identified in the significant change of condition “evaluation/assessment.” Interviews conducted on 02/25/26 at 2:00 pm with Staff RN 3 (RN), Staff 4 (RCC), and Staff 5 (RCC) confirmed the resident did not require Hoyer lift transfers prior to leaving the facility and that the service plan was not reviewed and updated to reflect the significant change of condition. The requirement to review and update the resident’s service plan following a significant change of condition was discussed with Staff 1 (ED) on 02/25/26 at 3:15 pm. She acknowledged the findings.

1.)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 C0260: 2.) (a-e)The Residents' service plans were reviewed and updated to reflect person-centered care. Staff were informed of the updates and reminded to review the updates and document their review on the signature page in order to ensure compliance. Ongoing monitoring of this requirement will be the responsibility of: The RCC, HSD, RN and the ED. The reviews will occur quarterly, and upon any significant change to a resident's status. Service plans for all residents were reviewed and evaluated for any changes that are needed. Weekly monitoring of service plan due dates will be completed by the RCC, HSD, RN and ED. Each service plan was reprinted with the most recent updates to each and placed in the appropriate binder for staff review on 3/14/2026. A document was created to organize and reflect the due dates of the upcoming quarterly service plans. The RCC, HSD, RN and ED will continuously monitor and replace any service plans as needed. All service plans will be evaluated, updated and printed prior to 4/25/26 3.)(a-c) The facility awknowledges the requirement that an initial service plan must be developed prior to move in. The service plan must be person centered and identify the residents needs. Staff will be required to review and sign all new service plans , and any changes or updates to a current resident. The RCC, HSD, RN and ED will be responsible for monitoring the requirement and will provide training to all current staff and new staff upon their initial training. A meeting was held on 3/10/26 where this requirement was communicated to the staff that attended. The RCC,HSD,RN and ED have developed a process for ongoing compliance and will continue to monitor and educate the staff. 4. (a-c) The facility awknowledges the requirement that service plans need to be reviewed quarterly following a resident's move in. The service plans for residents #1-3 were reviewed and updated immediately and their service plans will be revised quarterley, and as needed to reflect any changes in care and the historical information will be maintained. The service plans of all residents will be reflective of the current care needs, and will have clear and precise direction on who will provide the care and who will perfom the task. The service plan will be person centered to include ADL's , ablilty to perform tasks and what assistance they require from the staff.

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 implement actions or interventions for changes of condition, to monitor and note progress of the conditions, at least weekly, to resolution, and to evaluate and refer significant changes of condition to the RN for 3 of 3 sampled residents (#s 1, 2, and 3) who had documented changes of condition. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 10/2025 with diagnoses including Multiple Sclerosis, macular cyst, and migraines. Review of the resident's clinical record, from 11/23/25 through 02/23/26, revealed the following: * 12/29/25: a progress note written by Staff 6 (Contracted RN) stated, “This RN has asked for [his/her] monthly weight a handful of times and still have not seen that it was taken. Have requested it again today from the interim HSD and ED. Awaiting results to be able to evaluate for significant COC related to weights.” There were no weight-related notes documented for the next six weeks, and clinical records showed no weights were obtained. * 02/20/26: another progress note by Staff 6 stated, “This RN has not been able to determine if [Resident 3] has had a significant change in weight as still do not have a weight for this month. This RN has asked a number of times to have the weight collected. Will send a request for the weight again, and then the HSD/RN at the community will be able to evaluate for any possible significant weight changes.” On 02/25/26 at 12:50 pm, the need to maintain a system of monitoring each resident consistent with his or her evaluated needs and a reporting protocol to determine if a change in a resident’s condition required further action, was discussed with Staff 1 (ED). She acknowledged the findings. 2. Resident 1 was admitted to the facility in 10/2025 with diagnoses including chronic obstructive pulmonary disease (COPD) and congestive heart failure. The resident's 11/23/25 through 02/23/26 clinical record was reviewed, and the following was identified: * 12/10/25: “Bruising observed on right arm and legs.” * 12/15/25: “Many areas with skin discolorations.” * 12/20/25: “New skin discoloration side of thigh.” There was no documented evidence the facility had monitored any of the documented changes of conditions related to skin through resolution. During an interview on 02/25/26 at 2:10 pm, Staff 1 (ED) confirmed there was no documentation of skin monitoring. On 02/25/26, the need to ensure changes of condition related to skin were monitored, with progress noted at least weekly through resolution, was discussed with Staff 1, Staff 2 (Health Services Director), Staff 4 (RCC), and Staff 6 (Regional RN). They acknowledged the findings. 3. Resident 2 moved into the facility in 07/2024 with diagnoses including stroke resulting in right-sided hemiplegia and hemiparesis of the dominant side, Type 2 diabetes mellitus, and chronic obstructive pulmonary disease. The resident’s 11/23/25 through 02/23/26 clinical record was reviewed, and interviews with staff were conducted. The following was identified: a. A progress note dated 01/23/26 documented caregivers observed fresh blood during routine incontinence care and notified the RN of wounds to the resident’s bilateral buttocks, with a request for the RN to assess. In a progress note dated 01/23/26, Staff 3 (RN) documented being notified of wound openings to the sacral are, noted barrier cream was in use, and requested a Home Health referral from the primary care provider. There was no documented evidence that the facility determined and documented what action or intervention was needed for the resident when the wounds were identified on 01/23/26, nor was there documented evidence that the facility provided written communication of the resident’s change of condition and any required interventions to caregivers on each shift. b. A late entry progress note by Staff 3, dated 01/27/26, documented a sacral wound identified as a pressure ulcer. The note stated, “Additional wound information: Pink/light purple discoloration was from skilled nursing facility return. Area was initially blanching currently surrounding tissue is not blanching [sic].” The documentation indicated this was the initial wound assessment. No new orders had been received, and the facility was awaiting a Home Health referral. There was no documented evidence that following this assessment, the facility evaluated the resident and updated the service plan as needed, determined and documented what action or intervention was needed, provided written communication of the resident’s change of condition and any required interventions to caregivers on each shift, or monitored the resident consistent with evaluated needs. c. An outside provider note transcribed in the progress notes on 01/30/26, from a Home Health visit on 01/29/26, documented admission to start of care. The note stated, “3-stage II’s on [left and right buttocks] keep dry/clean! Please change foam dressing if soiled.” There was no documented evidence that following the 01/29/26 Home Health note identifying three stage II pressure ulcers and providing wound care instructions, the facility evaluated the resident, referred to the facility nurse, updated the service plan as needed, determined and documented required action or interventions, provided written communication of the resident’s change of condition and any required interventions to caregivers on each shift, or monitored the resident consistent with evaluated needs. d. A service plan addendum was not documented until 02/02/26, which included wound care instructions and direction to notify Home Health if the dressing became dislodged. A wound evaluation by Staff 3, dated 02/03/26, repeated the prior information documented from 01/27/26 and indicated that Home Health wound care orders had been received and services had started. There was no documented evidence that, between 01/23/26 and 02/02/26, the facility implemented resident-specific wound care interventions, ensured written communication of the resident’s change of condition and required wound care and monitoring to caregivers on each shift, or monitored the resident consistent with evaluated needs. Interviews conducted on 02/25/26 at 11:00 am with Staff 1 (ED), and at 11:25 am with Staff 3, confirmed there was no additional skin monitoring documentation. The need to ensure that when a resident experienced a significant change of condition the facility evaluated the resident, updated the service plan as needed, provided written communication of the change of condition and required interventions to caregivers on each shift, and monitored consistent with evaluated needs was discussed with Staff 1 (ED) on 02/25/26 at 3:15 pm. She acknowledged the findings.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring C0270 Residents #1-3 received a full chart audit that included the care plan, assistive device assessments, skin conditions,SPA's, short term health monitoring and an ABST review. The RCC, HSD, RN and ED were assigned the facilities Service plan Policy and Procedure as well as the change in condition policy. The RCC, HSD, RN and ED were assigned 3 courses through Oregon Care Partners related to the topics of change in condition and service plans. They will be completed by 4/24/26, Ongoing monitoring of changes in care will be reviewed weekly during the facilities SMART meeting that takes place weekly in the Nursing office.

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 a timely RN assessment was completed following significant changes of condition, including findings, resident status, and interventions made as a result of the assessment, for 2 of 3 sampled residents (#s 1 and 2) who experienced significant changes of condition. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 07/2024 with diagnoses including stroke resulting in right-sided hemiplegia and hemiparesis of the dominant side, Type 2 diabetes mellitus, and chronic obstructive pulmonary disease. The resident's clinical record was reviewed. Weight records identified the following: * 11/07/25 – 266 pounds; and * 01/28/26 – 238 pounds. Between 11/2025 and 01/2026, Resident 2 lost 28 pounds, or 10.5% of his/her total body weight, in two months, which constituted a severe weight loss. On 02/23/26, survey requested Resident 2 be weighed. The facility reported his/her weight was 233.8 pounds. Observations and interviews with staff indicated the resident was independent with dining and ate meals in his/her room. Progress notes documented by Staff 6 (Contract RN) on 01/17/26, 01/25/26, 02/07/26, 02/14/26, and 02/20/26 noted reported weight loss and inability to assess for significant weight loss due to lack of timely reweigh and missing weight documentation. There was no documented evidence that the RN completed a timely assessment of the resident following the identified weight loss between 11/07/25 and 01/28/26, which included findings, resident status, and interventions made as a result of an assessment. An interview conducted on 02/25/26, at 12:20 pm, with Staff 1 (ED) confirmed that no RN assessment was completed for Resident 2’s weight loss. The need to ensure the RN assessed residents with significant changes of condition in a timely manner and documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (ED) on 02/23/26 at 3:15 pm. She acknowledged the findings. 2. Resident 1 was admitted to the facility in 10/2025 with diagnoses including chronic obstructive pulmonary disease, congestive heart failure, and was receiving hospice services. The resident’s 11/23/25 through 02/23/26 clinical record was reviewed and revealed that in early December the resident had a significant decline of condition in multiple areas. An RN assessment was completed on 12/10/25, and the service plan was updated. The service plan indicated the resident was no longer eating, was drinking very little, needed assistance with all ADL cares, was primarily bed bound, had multiple falls, was very confused and difficult to understand, and was transitioning toward end of life. On 12/30/25 the hospice provider reported the resident “appears much clearer and no confusion noted.” On 01/02/26 the progress notes indicated the resident had left overnight to go home with his/her husband, and on 01/05/26 documentation indicated discussions around the resident moving back home. Observations and interviews were conducted with Resident 1 on 02/23/36 and 02/24/26 and revealed the resident was alert and oriented and independent with bed mobility, transfers, toileting, and ambulation in the apartment. Resident 1 reported being able to perform ADL tasks independently. Staff were observed to assist the resident with wheelchair mobility to and from the dining room and outside to smoke. The resident ate and drank independently. There was no documented evidence the RN had completed an assessment for the significant change of condition. On 02/23/26 at 3:15 pm, Staff 1 (ED) verified that the resident had improved and the RN needed to complete a significant change of condition assessment. Staff 6 (Regional RN) completed the assessment on 02/23/26 and updated the service plan on 02/24/26. The need to ensure a timely RN assessment was completed for significant changes of condition, which included resident status and interventions made as a result of the assessment, was discussed with Staff 2 (Health Services Director), Staff 6 (Regional RN), and Staff 4 (RCC) on 02/25/26 at approximately 1:00 pm, and Staff 1 at 2:20 pm. They acknowledged the findings.

OAR 411-054-0045 Resident Health Services C280 The RCC, HSD, RN and ED were assigned the facilities Service plan Policy and Procedure as well as the change in condition policy. The RCC, HSD, RN and ED were assigned 3 courses through Oregon Care Partners related to the topics of change in condition and service plans. They will be completed by 4/24/26, Ongoing monitoring of changes in care will be reviewed weekly during the facilities SMART meeting that takes place weekly in the Nursing office. The facilities department heads will be responsible for reviewing and ensuring that the staff in their department review any new and updated service plans.The ED will be responsible for ensuring that a Service Planning Team is apart of all service plans and that any changes in a service plan are documented by the licensed Nurse within 48 hours. Education and counseling of direct nursing staff will be provided on a regular basis. This will be the responsibility of the one or more of the following: RCC, HSD, RN, ED. Education will be documented and monitored by the ED.

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 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF 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) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF 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 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF 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 facility pathways were maintained in good repair. Findings include, but are not limited to: Observations of facility pathways on 02/23/26 and 02/24/26 identified the following: * Multiple drop-offs of 2-8 inches were noted along pathway edges. The pathway drop-offs were shown to Staff 1 (ED) and Staff 7 (Maintenance Director) on 02/25/26 at 9:15 am, and the need to ensure pathways around the facility were in good repair, with no potential tripping hazards was discussed. The staff acknowledged the findings.

OAR 411-054-0300 General Building Exterior (3)(a-h) The identified pathways and walkways were immedietly assessed by ED and Maintenance Director (MD). The facility has made a plan to purchase the appropriate rock/gravel to fill-in the identified drop-offs and uneven surfaces along the pathway. Potential tripping hazards on uneven walkways were reported via website workorder reporting portal to the City of Corvallis for repair. The facility has initiated contact with potential vendors for the purchase and installation of rock/gravel and fencing. Fencing will be installed near the larger drop-off areas to prevent Resident access and ensure safety. Ongoing inspections of the property will be conducted by the MD or designee to identify any additional uneven surfaces, drop-offs or hazards. All identified areas will be included in the repair plan. A weekly environmental rounding will be implemented with a focus on the safety of the walkways and any potential surface damage. Staff will be educated on how to report hazards or concerns related to uneven surfaces or drop offs immediately. The ED or designee will monitor maintenance logs weekly for 4 weeks, and then monthly after. Vendor bids were collected on 3/2/26 and a vendor will be selected by 3/25/26. The materials will be selected immediately upon bid approval. The installation is expected to begin by 3/30/26 with a completetion date of 4/21/26, weather permitting. If a delay occurs due to availability or weather, interim safety measures will be placed until full correction is completed.

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF 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) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF 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 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF 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: