Washington Gardens Memory Care

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

Based on interview and record review, it was determined the facility failed to ensure injuries of unknown cause and incidents of abuse or suspected abuse were promptly investigated to rule out abuse/neglect and were reported to the local Seniors and People with Disabilities (SPD) office if unable to reasonably conclude the incidents were not a result of abuse and/or neglect for 2 of 3 sampled residents (#s 2 and 3) who experienced repeated falls and/or injuries of unknown cause. Findings include but are not limited to: 1. Resident 3 moved into the memory care facility in 01/2023 with diagnoses including dementia with behavioral disturbances and hypertension. The resident's 07/22/25 and 10/22/25 service plans, Interim Service Plans (ISPs), 10/05/25 through 01/02/26 observation notes and 10/05/25 through 11/28/25 incident reports were reviewed. The 07/22/25 service plan indicated staff were to offer the resident toileting assistance “up to 4 times a shift to prevent falls” and to check on the resident “up to 8 times a shift.” The 10/08/25 ISP noted to keep the resident “in common area for better supervision.” a. Staff documented on 10/05/25 and 10/08/25 the resident fell and experienced bleeding from the head. There was no documented evidence the facility ruled out abuse or neglect for the above unwitnessed injury falls, including whether the service plan was being followed at the time of the falls. On 01/06/26 at 3:15 pm, Staff 1 (ED) confirmed the above incidents had not been reported to the local SPD office. b. Staff documented on 11/07/25 and 11/28/25 the resident had unwitnessed (injury or non-injury) falls, and abuse and neglect could not be ruled out. There was no documented evidence the incidents were reported to the local SPD as indicated in the reports. On 01/06/26 at 3:15 pm, Staff 1 confirmed the above incidents had not been reported to the local SPD office. c. The clinical records showed the following: * A 12/06/25 observation note identified “discoloration on left upper arm … increased swelling … additional bruising and fluid build up.” There was no documented evidence the injuries were immediately investigated to rule out abuse. On 01/06/26 at 3:15 pm, Staff 1 confirmed the above injuries lacked investigation and had not been reported to the local SPD office. The surveyor requested the above injuries be reported to the local SPD office, and confirmation was received on 01/07/26 at 2:33 pm. The need to investigate injuries of unknown cause and incidents of abuse or suspected abuse to rule out abuse and to notify the local SPD if abuse could not be ruled out was discussed with Staff 1 on 01/08/26 at 10:05 am. She acknowledged the findings. The surveyor requested the above incidents and injuries of unknown cause be reported to the local SPD office, and confirmation was received on 01/07/26 at 2:33 pm. 2. Resident 2 moved into the memory care facility in 02/2022 with diagnoses including dementia. The resident's 10/05/25 to 01/05/26 Observation notes, Interim Service Plans, incident reports, and incident investigations were reviewed, and interviews with staff and a witness were conducted. The following was identified: a. There was no documented evidence the following injuries of unknown cause were investigated to rule out abuse or neglect: * 12/13/25 7:33 am observation note: “Resident was found on the floor had redness on right knee”; and * 12/16/25 12:42 pm observation note: “Discoloration found all over resident’s left hand”. b. On 12/23/25 staff documented “[r]esident had an injury fall hit [her/his] head ... 911 came.” The incident investigation did not include the required components of: * Time, date, place and individuals present; * Description of the event as reported; * Response of staff at the time of the event; and * Follow-up action. The need to investigate injuries of unknown cause to rule out abuse or neglect of care, and to notify the local SPD if abuse could not be ruled out, and to include all required components on the investigation, was discussed with Staff 1 (ED) on 01/08/26 at 11:15 am. She acknowledged the findings. The surveyor requested the above injuries of unknown cause and incidents be reported to the local SPD office, and confirmation was received on 01/07/26 at 2:30 pm.

What action has been taken to correct the deficiency for the affected residents? • All cited incidents were reviewed. • When abuse or neglect could not be reasonably ruled out, the incidents were reported to the local Senior and People with Disabilities (SPD) office on January 7, 2026. How will community prevent reoccurrence of the deficiency? • The Health Services Director (HSD) was provided in-service education on: o P&P #2A: Accidents and Incidents, o P&P #2B: Abuse and Neglect, and o Oregon Administrative Rules related to incident investigation and mandatory reporting, including OAR 411-054-0028. • All care staff and medication technicians were in serviced on: o Incident recognition and reporting requirements, including completing Incident Reports in their entirety, documentation expectations, and timely notification of leadership. • The ED and HSD will ensure a prompt and thorough incident report is completed and documented for each incident. • The ED and HSD will jointly review all incidents, injuries of unknown cause, and allegations or suspicions of abuse or neglect to determine whether the facility can reasonably conclude the incident was not the result of abuse or neglect, in accordance with OAR 411-054-0028. 1/7/2026 1/28/2026 1/28/2026 and on-going 1/28/2026 and on-going 1/28/2026 and on-going Accepted Yes No 2. How will the system be corrected so this violation will not happen again? Accepted Yes No 3. How often will the area needing correction be evaluated? Accepted Yes No 4. Who will be responsible to see that the corrections are completed/monitored? Accepted Yes No P a g e 2 | 26 • When the ED and HSD are unable to reasonably conclude abuse or neglect did not occur, the incident will be promptly reported to the local SPD office within required timeframes. How will community monitor to ensure the deficiency does not recur? • The HSD will monitor Incident Reports to ensure they are completed accurately, thoroughly, and in compliance with facility policy and state regulations. • The ED will ensure follow-up investigations are completed for each incident. • The RVP and RNC will conduct routine audits of Incident Reports and investigations to ensure ongoing compliance with Oregon Administrative Rules and community policies. • Any identified concerns will result in immediate corrective action and staff re-education. Who is responsible for ensuring compliance? • Executive Director (ED) • Health Services Director (HSD) • Regional Vice President (RVP) • Regional Nurse Consultant (RNC) Date of compliance: 03/09/2026

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

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.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs, the facility administrator was responsible for ensuring the implementation of services, and service plans provided clear direction regarding the delivery of services for 3 of 3 sampled residents (#s 1, 2, and 3) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the memory care facility in 01/2023 with diagnoses including Alzheimer’s disease. S/he was subsequently admitted to hospice in 02/2025 with an admitting diagnosis of Alzheimer’s disease. Observations were made of the resident's care from 01/05/26 through 01/07/26. Interviews with the resident’s family member and facility staff were conducted, and the service plan dated on 07/16/25 and interim service plans were reviewed. Resident 1's service plan was not reflective of the resident's current needs and lacked staff instruction for the following: * Instructions for behaviors related to chewing on thumb, bedding, and different objects; * Unclear directions for regular versus pureed diet texture, and crushed versus whole medications; * Instructions to staff on liquid consistency to be provided to Resident 1; * Instructions on to whom to report weight gain or loss, and changes in appetite; and * Instructions for aspiration precautions and interventions while choking. Staff 11 (MT) was interviewed on 01/06/26 at 12:18 pm and stated Resident 1 was on a pureed texture diet and was administered medications crushed. However, she was unable to find any instructions in the electronic health records system, and the service plan available to staff stated the resident’s diet was regular texture and s/he should be administered medication whole with water. During the observation of meals from 01/05/26 through 01/08/26, Resident 1 was observed to have been served a pureed texture diet. During the interview on 01/07/26, Staff 9 (CG) stated Resident’s 1 behavior “has been more challenging the last six months, [Resident 1] likes to grab everything and chews [his/her] thumb and bedding.” The need to ensure service plans were reflective of residents' current care needs, the facility administrator was responsible for ensuring the implementation of services, and service plans provided clear directions to staff regarding the delivery of services was discussed with Staff 1 (ED) on 01/08/26 at 11:26 am. She acknowledged the findings. 2. Resident 3 moved into the memory care facility in 01/2023 with diagnoses including dementia with behavioral disturbance and hypertension. During the survey, the resident was observed to require the assistance of one staff member for transfers and toileting. The resident’s record was reviewed, including the current service plan dated 10/22/25 and interim service plans. Interviews with staff were conducted, and observations were made. The following was identified: Resident 3’s service plan lacked clear direction regarding the delivery of services and/or were not implemented in the following areas: * Conflicting information regarding transfer and toileting assistance, whether one staff or two staff members were required; * Use of a scoop-style of mattress while in bed; * Use of a cushion while in the wheelchair; * Use of an air mattress while in bed; * Providing a mechanical soft diet as outlined; * Providing activities as outlined; and * Providing repositioning status. The need to ensure service plans provided clear direction regarding the delivery of services and was implemented, was reviewed with Staff 1 (ED) on 01/06/26 at 3:15 pm and Staff 14 (Administrative Assistant/Concierge) on 01/07/26 at 10:35 am. They acknowledged the findings. 3. Resident 2 moved into the memory care facility in 02/2022 with diagnoses including dementia. The resident's 10/05/25 to 01/05/26 Observation notes, the 12/31/25 service plan, Interim Service Plans, incident reports, and incident investigations were reviewed, observations were made, and interviews with staff and a witness were conducted. The following was identified: The service plan was not implemented in the following areas: * The service plan documented the intervention “takes furosemide daily and requires weight monitoring” and “Trained staff will obtain her/his weight once weekly for monitoring.” Record review showed weights taken only three times between 10/05/25 and 01/05/26; and * A recommendation from Speech Therapy to “add extra moisture like gravy, ranch, butter etc.” had been documented in 02/2025 but not added to the service plan. In interview on 01/07/26 at 11:15 am, Staff 1 (ED) acknowledged weekly weights were not done as ordered, and the speech therapy recommendation had not been added to the service plan and therefore was not done. The need to ensure service plans were updated and implemented was reviewed with Staff 1 on 01/07/26 at 11:15 am. She acknowledged the findings.

What action has been taken to correct the deficiency for the affected residents? • The HSD was provided in-service education on: o P&P #5A-Initial Evaluation and Plan of Care, and o P&P #5B-Comprehensive Evaluation o Oregon Administrative Rules related to incident investigation and mandatory reporting, including OAR 411-004-0036 (1-4) • An updated, resident-centered service plan, that is reflective of residents’ current needs and provides clear direction of services was completed for Residents 1, 2, and 3. • HSD and ED will ensure implementation of all services indicated in the updated service plans. How will community prevent reoccurrence of the deficiency? • The Health Services Director (HSD) reviewed Policies and Procedures 5A and 5B related to assessments and service planning to ensure understanding of regulatory and facility expectations under OAR 411-054-0036 (1-4). • Moving forward, all assessments, including change of condition and scheduled assessments, will be completed in a resident-centered manner to ensure service plans are reflective of residents ‘current care needs and provide clear direction of services. • Service plans will be updated as needed to reflect changes in condition, care needs, and resident preferences. • HSD and ED will ensure that services identified in the service plan are communicated to and provided by 1/28.2026 Accepted Yes No 2. How will the system be corrected so this violation will not happen again? Accepted Yes No 3. How often will the area needing correction be evaluated? Accepted Yes No 4. Who will be responsible to see that the corrections are completed/monitored? Accepted Yes No P a g e 4 | 26 care staff by requiring care staff to review and initial updated service plans. How will community monitor to ensure the deficiency does not recur? • The HSD will complete resident assessments and develop resident-centered service plans in accordance with community policy and Oregon Administrative Rules. • The HSD will ensure proper implementation of resident services by conducting regular reviews of service plans and monitoring care staff performance. • The RVP and RNC will conduct frequent audits of assessments/service plans to ensure they are resident centered, are reflective of residents’ current care needs, and provide clear direction of services. • Any identified concerns will result in immediate corrective action and re-education as necessary. • HSD and the Lifestyle Director will meet to review and discuss any updated hobbies or new interests the resident has. • ABST will be updated after any change of condition and reviewed weekly following the community’s high-risk meeting to make sure staffing levels stay accurate and reflect each resident’s needs. • All ISPs will be signed by staff and entered the service plan when required to ensure the record reflects current care needs. Who is responsible for ensuring compliance? • Health Services Director (HSD) • Executive Director (ED) • Regional Vice President (RVP) • Regional Nurse Consultant (RNC) Date of full compliance: • 03/09/2026

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.

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.

Based on observation, interview, and record review, it was determined the facility failed to ensure resident-specific actions or interventions were determined, documented, and communicated to staff on all shifts for short-term changes of condition, residents were monitored consistent with evaluated needs, and/or weekly progress was noted until the condition resolved for 2 of 3 sampled residents (#s 2 and 3) who experienced short-term changes of condition. Findings include, but are not limited to: 1. Resident 3 moved into the memory care facility in 01/2023 with diagnoses including dementia with behavioral disturbance and hypertension. On 01/05/26 during the acuity interview, Resident 3 was identified to have multiple falls. The resident’s record was reviewed, interviews with staff were conducted, and observations were made. The following was identified: * During the survey, the resident was observed to require staff assistance for transfers, toileting and feeding; * The 07/22/25 service plan indicated the resident “is a high fall risk.” Interventions included one-on-one staff companionship for up to 20 minutes per shift, assistance with non-skid socks, encouraging participation in activities, offering toileting assistance up to four times per shift, promoting wheelchair use, assisting with reading once per shift, performing outfit checks up to twice per shift and providing music with “a little bit of lighting” at bedtime to help prevent falls; * It was also noted staff placed a floor mat at the resident’s bedside to help prevent injury when falling out of bed; and * The 10/08/25 interim service plan indicated to keep the resident “in common area for better supervision.” a. Staff documented the following falls: * 10/05/25 – fall with injury; * 10/08/25, 11/05/25 and 11/28/25 – unwitnessed falls with injuries; and * 11/07/25 – unwitnessed fall without injury. There was no documented evidence the resident was monitored consistent with evaluated needs and service plan, including to review each incident to identify the circumstances of the falls, determine whether staff followed the current interventions, evaluate the effectiveness of the current interventions, and determine if alternative interventions were needed to prevent further falls. b. Staff documented the following changes of condition: * 10/05/25 – laceration following a fall; * 10/08/25 – a fall resulting in bleeding from the back of the head; * 11/05/25 – a fall resulted in bleeding from the resident’s left arm; * 11/07/25 – a fall; and * 11/28/25 – a fall sustained a small cut on the resident’s elbow. The above changes in condition lacked documented progress at least weekly until resolved. On 01/06/26 at 3:15 pm, the above was reviewed with Staff 1 (ED) and 01/08/26 at 10:05 am. Staff 1 confirmed no weekly progress notes were documented until the conditions were resolved and acknowledged the resident was not monitored consistent with evaluated needs and service plan. The need to ensure the facility evaluated and determined what resident-specific actions or interventions were needed following repeat falls and monitored the resident consistent with evaluated needs and service plan, and documented progress at least weekly until resolved was reviewed with Staff 1 on 01/08/26 at 10:05 am. She acknowledged the findings. 2. Resident 2 moved into the memory care facility in 02/2022 with diagnoses including dementia and was identified in the acuity interview as having a history of repeat falls. The resident's 10/05/25 to 01/05/26 Observation notes and Interim Service Plans were reviewed, and interviews with staff and a witness were conducted. The following was identified: Staff documented on 12/23/25 the resident returned from the facility after an emergency room visit related to a chair hitting the back of his/her head from a fall. A TSP was created and documented only “R back of head” with no specific monitoring instructions or instructions for staff, such as monitoring for nausea, vomiting, or neurological changes. The need to ensure the facility monitored the resident consistent with evaluated needs and service plan was reviewed with Staff 1 (ED) on 01/07/26 at 11:15 am. She acknowledged the findings.

What action has been taken to correct the deficiency for the affected residents? • For the affected residents, corrective actions were implemented immediately upon identification, as monitoring documentation cannot be completed retroactively. How will community prevent reoccurrence of the deficiency? • The Health Services Director (HSD) was provided in-service education on: o P&P #5D-Alert Charting, and o P&P #5F-Interim Service Plans, and o P&P #5P-High-Risk Meeting • The HSD will provide education and review of these same policies with all care staff to ensure understanding of: o Identifying and responding to short-term changes of condition o Developing and documenting resident-specific actions and interventions o Communicating changes and care expectations to staff on all shifts o Monitoring residents based on evaluated needs o Completing alert charting documentation until the condition is resolved and discontinued by HSD. • Going forward, the HSD will ensure Interim Service Plans, Alert Charting, and High-Risk Meeting processes are completed in accordance with policy and that care staff consistently follow these processes. Any significant change of condition that is identified will 1/28/2026 Accepted Yes No 2. How will the system be corrected so this violation will not happen again? Accepted Yes No 3. How often will the area needing correction be evaluated? Accepted Yes No 4. Who will be responsible to see that the corrections are completed/monitored? Accepted Yes No P a g e 7 | 26 prompt the HSD to review and update the service plan accordingly. How will community monitor to ensure the deficiency does not recur? • The ED, RVP, AND RNC will complete frequent audits of: o Interim Service Plans o Alert charting o High-risk meeting documentation o Weekly progress notes related to short-term changes of condition • Audit findings will be reviewed with the ED and HSD, and corrective action and re-education will be completed as needed to ensure sustained compliance. Who is responsible for ensuring compliance? • Health Services Director (HSD) • Executive Director (ED) • Regional Vice President (RVP) • Regional Nurse Consultant (RNC) Date of full compliance: • 03/09/2026

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.

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.

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 2 of 2 sampled residents (#s 1 and 3) who experienced significant changes of condition. Findings include, but are not limited to: 1. Resident 1 moved into the memory care facility in 01/2023 with diagnoses including Alzheimer’s disease. S/he was subsequently admitted to hospice in 02/2025. Clinical records, including the current service plan, dated 07/16/25, progress notes from 10/07/25 through 01/05/26, weight records from 08/2025 through 01/2026 were reviewed. Interviews with facility staff were conducted. According to the resident's service plan, the resident's weight was scheduled to be taken each month “for RN monitoring.” The following weights were recorded by the facility: * 08/2025 - no weight recorded; * 09/02/2025 – 141.6 pounds; * 10/17/2025 – 132.8 pounds; * 11/19/2025 – 116.0 pounds; * 12/01/2025 – 122.2 pounds; and * 01/06/26 - Resident was weighed per surveyor request and recorded to be 114.8 pounds. The resident experienced an 8.8-pound weight loss, or 6.21% of his/her total body weight, in one month (09/03/25 through 10/17/25) and an additional 16.8 pound weight loss, or 12.65% of his/her total body weight, in the next consecutive month (10/17/25 through 11/19/25). This represented a significant change of condition. The resident experienced an additional significant change of condition with the loss of 7.4 pounds in one month, or 6.05% of his/her total body weight, between 12/01/25 and 01/06/26. During an interview on 01/06/26 at 2:35 pm, Staff 2 (Health Service Director/RN) stated, “Hospice does weight clinic for everyone in the facility.” Staff 2 indicated she entered the hospice weight data in the facility’s electronic health records system. During meal observations conducted in the dining room from 01/05/26 through 01/07/26 the following was noted: * 01/05/26 – The resident was fed lunch from 12:18 pm to approximately 12:30 pm. His/her total intake was 100%; * 01/06/26 - The resident was fed lunch from 12:05 pm to approximately 12:14 pm and ate 100%; and * 01/07/26 - The resident was fed lunch from 12:10 pm to approximately 12:15 pm and ate 100%. During an interview on 01/07/26 at 12:15 pm, Staff 9 (CG) stated, "You never know with [Resident 1], if [s/he] is hungry or not. Always opens [his/her] mouth and eats fast." The ongoing weight loss constituted a significant change of condition requiring an RN assessment. There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment. A treatment order from hospice was received on 01/07/26, while the survey team was on site, stating “no interventions needed for weight loss as it is expected due to disease progression.” The need to ensure an RN assessment was completed for all residents who experienced a significant change of condition was discussed with Staff 1 (ED) on 01/08/26 at 11:26 am. She acknowledged the findings. 2. Resident 3 moved into the memory care facility in 01/2023 with diagnoses including dementia with behavioral disturbance. On 01/05/26 during the acuity interview, Resident 3 was identified as requiring one-on-one meal intake assistance from staff. During the survey the resident was observed receiving assistance from staff for meal intake. Resident 3's weight record was reviewed, and the following was noted: * 09/03/25 – 85.4 pounds; * 11/29/25 – 86 pounds; * 12/18/25 – 79.2 pounds; and * 01/06/26 – 81.6 pounds (during the survey). Review of the weight record indicated Resident 3 experienced a loss of 6.9 pounds, or 7.9 % body weight, between 11/29/25 and 12/18/25. This represented a significant change of condition for which an RN assessment of the weight loss was required. There was no documented evidence a facility RN completed an assessment which included findings, resident status and interventions made as a result of the assessment. During an interview on 01/06/26 at 10:55 am Staff 2 (Health Services Director/RN) confirmed she did not complete the assessment for the resident’s weight loss. The need to ensure a RN assessment was completed for residents who experienced a significant weight loss was discussed with Staff 2 on 01/06/26 at 10:55 am and Staff 1 (ED) on 01/06/26 at 3:15 pm. They acknowledged the findings.

What action has been taken to correct the deficiency for the affected residents? • Residents identified as having experienced a significant change of condition were reviewed. The HSD completed a change of condition assessment as required, and findings were documented and communicated to appropriate staff. How will community prevent reoccurrence of the deficiency? • The HSD was provided in-service education on: o P&P #5E – Change of Condition Assessments, and o P&P #5G – Weight Variance, specifically how weight changes trigger and apply to change of condition assessments. o OAR 411-054-0045 (1)(a-f)(A)(C-F) • Education included identification of significant changes of condition, timely RN assessment requirements, documentation standards, and communication of findings. How will community monitor to ensure the deficiency does not recur? • The HSD will notify RVP and RNC of change of condition assessments completed. • The RVP and RNC will conduct routine audits of change of condition assessments to ensure compliance with policy and OAR requirements. • Audit results will be reviewed and corrective action and re-education will be completed as needed. Who is responsible for ensuring compliance? • Health Services Director (HSD) Accepted Yes No 2. How will the system be corrected so this violation will not happen again? Accepted Yes No 3. How often will the area needing correction be evaluated? Accepted Yes No 4. Who will be responsible to see that the corrections are completed/monitored? Accepted Yes No P a g e 9 | 26 • Executive Director (ED) • Regional Vice President (RVP) • Regional Nurse Consultant (RNC) Date of full compliance: 03/09/2026

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.

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

Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment related to incontinence care for 1 of 2 sampled residents (# 3) whose care was observed. Findings include but are not limited to: Observations were made during the survey to determine adherence to universal precautions for infection control. On 01/05/26, approximately 11:20 am, 01/06/26 at 9:50 am, the surveyor obtained permission and observed Staff 10 (CG) on 01/05/26 and Staff 6 (CG) on 01/06/25 provide incontinence care to Resident 3. During the observations, Staff 6 and Staff 10 failed to change gloves after removing a soiled incontinent product and wiping fecal matter from Resident 3's bottom area. Staff 6 and Staff 10 applied a new brief to Resident 3 and touched the resident's pants and the manual wheelchair while wearing the same soiled gloves. When Staff 6 and Staff 10 were finished providing incontinent care then they removed the gloves. During the observations, staff failed to change gloves between clean and dirty tasks. The need to ensure staff consistently used universal precautions was discussed with Staff 1 (ED) on 01/06/26 at 3:15 pm. She acknowledged the findings.

What action has been taken to correct the deficiency for the affected residents? • The community immediately addressed incontinence care practices to ensure residents receive care consistent with infection prevention and control standards. Staff were instructed on proper hand hygiene and glove use during incontinence care to reduce risk of infection and maintain a sanitary environment. How will community prevent reoccurrence of the deficiency? • The HSD will review P&P #4A– Infection Control with all staff to reinforce expectations and compliance requirements with emphasis on: o Hand hygiene before and after resident contact, o Proper glove use during incontinence care, and o Appropriate disposal of soiled materials. How will community monitor to ensure the deficiency does not recur? • The HSD will frequently observe care staff during incontinence care to ensure proper infection control techniques are being followed and report findings to ED, RVP, and RNC. • The RVP and RNC will conduct routine audits and observations related to infection prevention practices. • Identified concerns will be addressed promptly with corrective action and re-education as needed. Accepted Yes No 2. How will the system be corrected so this violation will not happen again? Accepted Yes No 3. How often will the area needing correction be evaluated? Accepted Yes No 4. Who will be responsible to see that the corrections are completed/monitored? Accepted Yes No P a g e 11 | 26 Who is responsible for ensuring compliance? • Health Services Director (HSD) • Executive Director (ED) • Regional Vice President (RVP) • Regional Nurse Consultant (RNC) Date of full compliance: 03/09/2026

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

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work.

Based on interview and record review, it was determined the facility failed to have a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: During the entrance conference on 01/05/26 with Staff 1 (ED), Staff 2 (Health Services Director/RN) and Staff 5 (MT) the following was identified: * The facility was a one story MCC with two segregated units separated by locked doors and a lobby. The facility had a current census of 27 residents; * Five residents required a two-person assist to transfer and/or for ADL care. Three resided in the 100/200 neighborhood and two resided in the 300/400 neighborhood; * Two residents required meal assistance; and * One resident required support for behavioral symptoms. On 01/07/26 at 1:21 pm, Staff 1 confirmed the number of two person transfers and indicated 27 of 27 residents require support for cognitive impairments. The facility's posted staffing plan and the staffing schedule from 12/28/25 to 01/03/26 were reviewed. The facility's posted staffing plan indicated the following: * Day Shift: 6:00 am - 2:00 pm - 3 CGs and 1 MT in 100/200 Neighborhood, and 2 CGs and 1 MT in 300/400 Neighborhood; * Swing Shift: 2:00 pm - 10:00 pm - 3 CGs and 1 MT in 100/200 Neighborhood and 2 CGs and 1 MT in 300/400 Neighborhood; and * Night Shift: 10:00 pm - 6:00 am - 2 CGs and 0.5 MT in 100/200 Neighborhood and 1 CG and 0.5 MT in 300/400 Neighborhood. The staffing schedule from 12/28/25 to 01/03/26 showed four day, three swing, and two night shifts in the 100/200 Neighborhood where the facility failed to follow their staffing plan. This was confirmed in an interview with Staff 1 on 01/08/26 at 10:40 am. The need to have a sufficient number of staff to meet all scheduled and unscheduled needs of residents on the day, swing and night shifts was discussed with Staff 1 on 01/07/26 and 01/08/26. She acknowledged the findings. No further information was provided.

What action has been taken to correct the deficiency for the affected staff? • The community immediately reviewed the posted staffing plan and actual schedules to identify gaps in required coverage. • Updates to the ABST weekly during change of condition or Weekly High Risk Meetings. • Staffing schedules were corrected and adjusted to meet the required staffing levels for all shifts and both neighborhoods. • Staff were reassigned between neighborhoods as needed to support two-person assists, ADLs, meal support, and behavioral needs. • Leadership responsible for scheduling were re educated on staffing plan and acuity-based coverage requirements. How will community prevent reoccurrence of the deficiency? • Leaders were re-educated on staffing plan compliance and minimum coverage requirements. • reviewed weekly during the High Risk meeting to ensure they continue to match resident acuity and care needs. • ABST updates are submitted to the State bi weekly, including current staffing levels, ABST totals, and onboarding updates. • The Executive Director, Health Services Director, and Resident Care Coordinator review the WhenToWork scheduling platform regularly to identify any open or unsigned shifts and ensure they are filled. Accepted Yes No 2. How will the system be corrected so this violation will not happen again? Accepted Yes No 3. How often will the area needing correction be evaluated? Accepted Yes No 4. Who will be responsible to see that the corrections are completed/monitored? Accepted Yes No P a g e 13 | 26 How will community monitor to ensure the deficiency does not recur? • The WhenToWork schedule will be checked routinely for open or unsigned shifts, and any gaps will be filled immediately. • Staffing and acuity levels will be reviewed during the weekly High Risk meeting to ensure staffing matches current resident needs, including two-person assists and high-support residents. • Bi-weekly ABST and staffing reports submitted to the State will be used as an additional compliance check. Health Services Director (HSD) • Executive Director (ED) • Regional Vice President (RVP) • Resident Care Coordinator (RCC) Date of full compliance: 03/09/2026

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work.

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

Based on interview and record review, it was determined the facility failed to ensure the facility’s acuity-based staffing tool (ABST) was updated following a significant change of condition and no less than quarterly, at the same time the resident’s service plan was updated, for 2 of 4 sampled residents (#s 1 and 2) and multiple unsampled residents whose ABST evaluations were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the memory care facility in 01/2023 with diagnoses including Alzheimer’s disease. The resident experienced a Stage 2 pressure ulcer, noted on 12/27/25, which constituted a significant change of condition. The resident’s ABST was not updated after his/her significant change of condition. 2. Resident 2 moved into the memory care facility in 02/2022 with diagnoses including dementia. There was no documented evidence the ABST data for Residents 2 had been updated quarterly. 3. Fifteen unsampled resident ABST evaluations had not been updated within the last 90 days. The need to ensure the facility ABST was updated with a significant change of condition, and no less than quarterly was discussed with Staff 1 (ED) on 01/07/26 at 3:55 pm. She acknowledged the findings.

1. What actions will be taken to correct the rule violation for each example/resident? What action has been taken to correct the deficiency for the affected residents? • ABST reviews and updates were completed for Residents #1 and #2. • All current resident ABST assessments were audited and updated where overdue. • The unsampled resident ABSTs identified as out of date were immediately brought into compliance. How will community prevent reoccurrence of the deficiency? • staff were re-educated on ABST update timing and documentation requirements. • The Executive Director and Health Services Director are responsible for ongoing oversight and routine audits to maintain compliance. • The ABST is updated after any change of condition and reviewed and updated as needed following each weekly High Risk meeting. • The ABST and staffing plan are submitted to the State on a bi-weekly basis to support continued compliance and oversight. How will community monitor to ensure the deficiency does not recur? • ABST status will be reviewed during the weekly High Risk meeting and change of condition and any needed updates will be completed at that time. • Bi-weekly ABST and staffing plan submissions to the State provide an additional external compliance check. Accepted Yes No 2. How will the system be corrected so this violation will not happen again? Accepted Yes No 3. How often will the area needing correction be evaluated? Accepted Yes No 4. Who will be responsible to see that the corrections are completed/monitored? Accepted Yes No P a g e 15 | 26 • Daily audits by Executive Director, Health services, and Resident Care Coordinator When to Work Schedule for updates into staffing • Health Services Director (HSD) • Executive Director (ED) • Regional Vice President (RVP) • Resident Care Coordinator (RCC) Date of full compliance: 03/09/2026 What action has been taken to correct the deficiency for the affected staff? • fire drill form implemented with all required documentation fields • Staff will be trained on fire drill and documentation requirements • Fire and life safety training completed and documented • Alternating month drill and training schedule will be created • Executive Director reviews and signs each record for compliance How will community prevent reoccurrence of the deficiency? • Use standardized fire drill form for every drill going forward • Schedule drills and fire/life safety trainings on alternating months • Rotate and document primary and alternate evacuation routes each drill • Executive Director reviews and signs all drill and training records • Monthly audit of fire drill and training documentation • Ongoing staff refreshers on fire drill and life safety requirements How will community monitor to ensure the deficiency does not recur? • The Executive Director will review and sign each fire drill and fire/life safety training record after completion to confirm all required elements are P a g e 16 | 26 documented. A monthly audit of drill and training documentation will be completed and tracked on the community compliance calendar. Any missing information will be corrected right away, with follow-up coaching provided to staff. Compliance will also be reviewed regularly during leadership safety meetings to ensure the issue does not recur. Who is responsible for ensuring compliance? • Executive Director (ED) • Regional Vice President (RVP) • Environmental Service Director (ESD) Date of full compliance: 03/09/2026

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

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.

Based on interview and record review, it was determined the facility failed to conduct fire drills according to the Oregon Fire Code (OFC) and failed to provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to: 1. Fire drill records from 08/2025 through 01/2026 were reviewed with Staff 3 (Housekeeping/Maintenance) on 01/07/26 at 10:35 am. Fire drill records lacked documentation that the following required elements were consistently followed: * Escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; and * Evidence alternate routes were used during fire drills. 2. There was no documented evidence the facility provided fire and life safety training to staff on alternate months. The need to ensure all required components were addressed and documented for each fire drill, and that drills were conducted on alternate months from fire and life safety training, was discussed with Staff 1 (ED) at 3:55 pm on 01/07/26. She acknowledged the findings.

1. What actions will be taken to correct the rule violation for each example/resident? What action has been taken to correct the deficiency for the affected staff? • fire drill form implemented with all required documentation fields • Staff will be trained on fire drill and documentation requirements • Fire and life safety training completed and documented • Alternating month drill and training schedule will be created • Executive Director reviews and signs each record for compliance How will community prevent reoccurrence of the deficiency? • Use standardized fire drill form for every drill going forward • Schedule drills and fire/life safety trainings on alternating months • Rotate and document primary and alternate evacuation routes each drill • Executive Director reviews and signs all drill and training records • Monthly audit of fire drill and training documentation • Ongoing staff refreshers on fire drill and life safety requirements How will community monitor to ensure the deficiency does not recur? Accepted Yes No 2. How will the system be corrected so this violation will not happen again? Accepted Yes No 3. How often will the area needing correction be evaluated? Accepted Yes No 4. Who will be responsible to see that the corrections are completed/monitored? Accepted Yes No P a g e 18 | 26 • The Executive Director will review and sign each fire drill and fire/life safety training record after completion to confirm all required elements are documented. A monthly audit of drill and training documentation will be completed and tracked on the community compliance calendar. Any missing information will be corrected right away, with follow-up coaching provided to staff. Compliance will also be reviewed regularly during leadership safety meetings to ensure the issue does not recur. Who is responsible for ensuring compliance? • Executive Director (ED) • Regional Vice President (RVP) • Environmental Service Director (ESD) Date of full compliance: 03/09/2026

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.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept.

Based on interview and record review, it was determined the facility failed to ensure each resident was instructed within 24 hours of admission and re-instructed, at least annually, in fire and life safety procedures. Findings include, but are not limited to: Facility fire and life safety records were reviewed on 01/07/26. The facility lacked documented evidence residents were instructed in general safety procedures, evacuation methods, and responsibilities during fire drills within 24 hours of admission and at least annually. On 01/07/25 at 1:25 pm, Staff 1 (ED) confirmed there was no system in place for instructing residents of the facility’s fire and life safety procedures. The need to ensure the facility instructed residents on fire and life safety procedures within 24 hours of admission and at least annually was reviewed with Staff 1 (ED) on 01/07/26 at 3:55 pm and on 01/08/26 at 10:51 am. She acknowledged the findings.

What action has been taken to correct the deficiency for the affected staff? • All current residents will be instructed on fire and life safety procedures, evacuation methods, and resident responsibilities. • Instructions were completed immediately after the finding. • Documentation of the instruction was added to each affected resident’s record. How will community prevent reoccurrence of the deficiency? • Fire and life safety instructions will be added to the admission checklist and move-in process. • Residents will be instructed within 24 hours of admission and at least annually after that. • A standard fire and life safety instruction form will be completed and filed in the resident record. • Staff were re-educated on the requirement and timeline. • Instruction will be assigned to a designated leader to ensure completion. How will community monitor to ensure the deficiency does not recur? • Leadership will review all new admission files weekly to confirm fire and life safety instruction is completed within 24 hours and documented. • Quarterly resident record audits will verify annual re-instruction is completed and on file. • The admission checklist will be reviewed for completion and sign-off. Accepted Yes No 2. How will the system be corrected so this violation will not happen again? Accepted Yes No 3. How often will the area needing correction be evaluated? Accepted Yes No 4. Who will be responsible to see that the corrections are completed/monitored? Accepted Yes No P a g e 20 | 26 • Any missing instruction or documentation found will be corrected immediately and tracked. Who is responsible for ensuring compliance? • Executive Director (ED) • Regional Vice President (RVP) • Environmental Service Director (ESD) Date of full compliance: 03/09/2026

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept.

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.

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 not limited to: Refer to C231, C295, C360, C363, C420, C422

Please refer to POC for: CO231, CO295, CO360, CO363, CO420 and CO422 Date of full compliance: 03/09/2026

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.

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request.

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 newly-hired non-direct care staff (#15) had completed all required pre-service dementia training, and 3 of 3 newly-hired direct care staff (#s 16, 17, and 18) completed all required pre-service dementia training topics. Findings include, but are not limited to: Staff training records were reviewed on 01/05/26 at 11:40 am with Staff 14 (Administrative Assistant/Concierge). The following was identified: a. There was no documented evidence Staff 15 (Cook), hired 09/30/25, had completed one or more of the following pre-service dementia care topics before completing any job duties: * Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to distressful behavioral symptoms; * Strategies for addressing social needs and engaging persons with dementia in meaningful activities; and * Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of a person-centered approach. On 01/05/26 at 11:40 am, Staff 14 confirmed she was not aware the pre-service dementia care topics were required for dietary and housekeeping staff. b. There was no documented evidence Staff 16 (CG), Staff 17 (CG), and Staff 18 (MT/CG), hired 11/23/25, 09/28/25, and 08/25/25, respectively, completed training in the use of supportive devices with restraining qualities in memory care communities. The need to ensure the required pre-service training was completed by staff in the time frames specified was discussed with Staff 1 (ED) on 01/07/26 at 3:55 pm and on 01/08/26 at 10:40 am. She acknowledged the findings.

What action has been taken to correct the deficiency for the affected staff? • Affected staff were immediately removed from independent duty until required pre-service dementia training was completed. • All missing dementia training topics were assigned and completed. • Training completion was verified by leadership and documented in each employee’s training file. • Staff were cleared to return to regular duties only after training requirements were fully met. How will community prevent reoccurrence of the deficiency? • A dementia pre-service training checklist has been added to the onboarding process for all new hires, including non-direct care staff. • No employee will be scheduled to work independently until required dementia training is completed and verified. • The Executive Director or designee will review and sign off on training completion before schedule release. • Training requirements and timelines have been re-reviewed with all department heads. • Monthly audits of training records will be conducted to ensure ongoing compliance. How will community monitor to ensure the deficiency does not recur? • The Executive Director or designee will conduct monthly audits of staff training records. Accepted Yes No 2. How will the system be corrected so this violation will not happen again? Accepted Yes No 3. How often will the area needing correction be evaluated? Accepted Yes No 4. Who will be responsible to see that the corrections are completed/monitored? Accepted Yes No P a g e 23 | 26 • All new hire files will be reviewed within the first week of hire to confirm required dementia training is complete. • A training compliance log will be maintained and reviewed during leadership meetings. • Any missing training will be assigned immediately, and staff will not work independently until completed. • Audit results will be documented and retained for compliance review. Who is responsible for ensuring compliance? • Health Services Director (HSD) • Executive Director (ED) • Regional Vice President (RVP) • Regional Nurse Consultant (RNC) Date of full compliance: 03/09/2026

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility.

Based on interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 260, C270, C280

Please refer to POC for C260, C270, AND C280.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility.

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities.

Based on interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed based on the activity evaluation, and a selection of daily structured and non-structured activities were included on the residents’ activity service plan for 3 of 3 sampled residents (#s 1, 2, and 3) whose service plans were reviewed. Findings include, but are not limited to: Resident 1, 2, and 3's current service plans were reviewed during the survey. Each of the service plans lacked documentation of an individualized activity plan for the resident and a selection of daily structured and unstructured activities. The need to develop an individualized activity plan for the resident and include it in the resident’s service plan was discussed with Staff 1 (ED) on 01/08/26 at 11:26 am. She acknowledged the findings.

What action has been taken to correct the deficiency for the affected residents? • Service plans for residents identified during survey were reviewed and updated to include individualized activity plans based on the activity evaluation, with a selection of daily structured and unstructured activities appropriate to each resident. How will community prevent reoccurrence of the deficiency? • The HSD was provided in-service education on: o OAR 411-057-0160 (2d) o Community’s Activity Policy • The HSD will ensure all service plans include: o An individualized activity plan based on the resident’s activity evaluation o A selection of daily structured and unstructured activities • Expectations for inclusion of individualized activity plans will be reinforced with appropriate staff involved in service plan development and review. How will community monitor to ensure the deficiency does not recur? • The ED, RVP, and RNC will conduct frequent audits of active service plans to ensure individualized activity plans and daily structured and unstructured activities are documented. • Audit findings will be reviewed, and corrective action and re-education will be completed as needed. Who is responsible for ensuring compliance? • Health Services Director (HSD) • Executive Director (ED) • Regional Vice President (RVP) • Regional Nurse Consultant (RNC) Date of full compliance: 03/09/2026

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 11/21/23 at 11:00 am, the kitchen was observed to need cleaning in the following areas: * Interior and exterior of the microwave; * Lids of food storage containers in the dry storage area; and * The exterior doors of reach in refrigerators and freezer. Items in the refrigerator were not sealed closed to prevent potential cross contamination, including an open bag of peeled garlic and a block of butter. One staff was not using any type of beard restraint. During food preparation observations there was a lack of appropriate glove use including the failure to wash hands when changing gloves. The areas were discussed with Staff 1 (Executive Chef) and Staff 2 (Executive Director) on 11/21/23. The findings were acknowledged.

1) The actions that will be taken to correct the rule violation include: a) The microwave will be replaced to ensure its integrity. A daily cleaning task list will be signed off by staff on duty to ensure cleanliness. b) The lids from the food storage containers will be cleaned inbetween meal services, and will have a documented weekly cleaning task list signed off by staff on duty to ensure cleanliness. c) The exterior doors of reach in refridgerators will be cleaned inbetween meal services and will be signed off on a daily cleaning task list. d) All items in the refrigerator are covered, dated, and properly labeled. e) All employees who are involved in the preparation of food will be required to wear a beard restraint. f) All employees who are involved in the preparation of food will be required to wash their hands inbetween changing gloves. 2) The system will be corrected so this does not occur again by: a) Daily and weekly cleaning task lists to observe the the microwave, food storage container lids, exterior refridgerator doors are cleaned. b) All employees who are involved in the preparation of food will complete "Food Safety Fundamentals" through Relias training by 1/20/24. c) Executive Chef or designee will ensure there are hair and beard restraints prior to entry to the kitchen. 3.The areas needing correction will need to be monitored daily and monthly through daily/weekly checklist audits. All employees who are involved in the preparation of food will be trained through the "Food Safety Fundamentals" on proper hand washing techniques and santiation by 1/20/24. 4. The Executive Chef and Administrator will be responsible for ensuring corrections are completed/monitored.

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240.

See Plan of Corrections (POC) for all citations.

The findings of the kitchen inspection, conducted 11/21/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the first revisit to the kitchen inspection of 11/21/23, conducted 03/01/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 05/23/2023.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 05/23/2023.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT:             Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse

Based on interview and record review it was confirmed the facility failed to orient direct care staff to the resident. Findings include: Review of facility Incident Report and Investigation Worksheet dated 09/15/2022, Investigation, and witness statement reveal that Staff # 3 was unaware of Resident # 1 having a POLST with DNR in place and direct care staff started CPR against resident wishes. Interview with Staff # 1 and Staff # 2 on 10/27/2022 with both stating that Staff # 3 did not know that Resident # 1 had a POLST with DNR. Facility Correction Plan: Facility provided in-service training on 10/25/2022 on POLST and CPR to staff.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 10/27/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Based on observation and interview, it was determined the facility failed to implement effective methods of infection control. Findings include, but are not limited to: Resident 2 was admitted to the MCC facility in November 2020. During the acuity interview on 10/10/22, staff reported the resident had a catheter. Observations were conducted during the survey to determine adherence to universal precautions for infection control. * Multiple observations during the survey, revealed Resident 2's catheter bag was hanging off the side of the resident's hospital bed and was touching the floor. * On 10/11/22 two CGs provide ADL care to Resident 2. During the observation, one of the CGs noted the tip on the catheter drain tube had become disconnected and was touching the floor. She reconnected the drain tube and failed to ensure the tube was sanitized prior to reconnecting.   * On 10/12/22 at 10:38 am, Staff 16 (MT) provided ADL care which included catheter care and incontinent care. Staff 16 was observed to place the catheter bag on the floor and repeatedly stepped on the catheter bag while ADL care was provided. When the task was completed, the catheter bag was picked up from the floor and placed on the bed, laying flat, level with the resident's bladder. The need to ensure proper infection control protocols were followed during ADL care was discussed with Staff 1 (ED), Staff 3 (Health Service Director/RN) and Staff 4 (RCC) on 10/12/22. They acknowledged the findings.

To ensure resident #2 receives proper catheter care following infection control guidelines, the following will be completed:  1. HSD provided immediate training to staff present on proper catheter care and infection control on October 11, 2022.  2.  Pinnacle Hospice to provide training to all staff on catheter care and infection control on November 10, 2022.  3.  Further re-education for Relias, staff are scheduled for the "Basics of Infection Control," and "Catheter Care" with dates of completion of November 25, 2022.   System to prevent re-occurrence, BOM will assign the above 2 Relias modules upon on-boarding new hires.  ED, HSD, RCC will do monthly observation of staff to verify proper infection control techiques.

3. Resident 3 was admitted to the facility in February 2020 and was dependent on staff for all ADL care needs. A review of the resident's clinical record identified the following: On 10/02/22, staff documented on a progress note that the resident had a purple colored bruise to the pubis area. On 10/05/22 (three days later), Staff 3 (Health Services Director/RN) documented on a progress note that the bruise appeared to be consistent with a bruise from a transfer and abuse and neglect was ruled out. There was no evidence the facility conducted an immediate and thorough investigation which included the following required components: * Time, date, place and individuals present; * Description of the event as reported; * Response of staff at the time of the event; * Follow-up action; and * Administrator's review. In an interview on 10/12/22, Staff 3 stated she had self-reported the injury on 10/10/22. Verification the injury of unknown cause was reported to the local SPD office was received on 10/12/22. The need to ensure injuries of unknown cause were investigated promptly and reported as necessary was discussed with Staff 3 on 10/12/22 . She acknowledged the findings. 2. Resident 1 was admitted to the facility in January 2020 with diagnoses including dementia. The clinical record revealed: On 08/04/22 and 08/05/22, the resident experienced two falls. A review of the incident and investigation reports showed no documented evidence the facility thoroughly investigated the falls in order to rule out abuse or neglect or reviewed the service plan to determine if it was being followed. The need to ensure a thorough investigation of falls and injuries in order to rule out abuse or neglect was completed and ensure service plans were being followed to prevent further injury was discussed with Staff 1 (ED) and Staff 4 (RCC) on 10/12/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to conduct investigations that included information to rule out abuse or neglect. The facility failed to conduct investigations for injuries of unknown cause and report the injuries as suspected abuse to the local Seniors and People with Disabilities (SPD) office, for 3 of 3 sampled residents (#s 1, 2 and 3). Findings include, but are not limited to: 1. Resident 2 was admitted to the MCC facility in 11/2020 and was dependent on staff for all ADL care needs. His/her clinical record revealed the following injuries of unknown cause: * On 08/01/22 a bruise to left forearm; * On 08/11/22 a skin tear to left forearm; * On 09/12/22 a yellowish bruise to left shin; * On 09/18/22 a skin tear/ scrape to right forearm; and * On 09/26/22 bruises to bilateral lower extremities and right hand. There was no documented evidence the facility immediately investigated and documented the injury was not the result of abuse or neglect. The facility did not report the injury to the local SPD office as suspected abuse/neglect. The need to ensure injuries of unknown cause were investigated promptly to rule out abuse and neglect or reported if necessary was discussed with Staff 3 (Health Services Director/RN) on 10/11/22. She acknowledged the facility had not investigated to rule out abuse/neglect. Verification the facility reported the five injuries of unknown cause to the local SPD office was received on 10/12/22.

Facility completeted required reporting prior survey exit on 10-13-22.  Facility to conduct in service training with staff on Abuse and Reporting and Investigation Guidelines for Providers by December 1, 2022.  Executive Director and/or Designee will be responisble for conducting investigations and meeting reporting requirements on an ongoing basis. Random compliance audits will be conducted by regional team (VPO and/or Nurse Consultant) on biannual basis.  RCC to attend the next Role of the RCC Course through OHCA once offered.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was kept clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the kitchen on 10/10/22 through 10/12/22 showed the following: * The dish machine faceplate indicated that it used high temperature water and the rinse cycle were required to reach 180 degrees F (Fahrenheit) to sanitize the dishes. Observation with Staff 8 (Executive Chef) showed the rinse cycle reached only 171 degrees F. Staff acknowledged the failure to reach the required temperature and used disposable plates and cups for all meals until the dish machine was serviced on 10/11/22, when a technician confirmed the water temperature was 188 degrees F., and a replacement gauge was ordered. * The back room sink leaked water around the faucet, and was loose. Staff 8 stated it had not been usable for months; * The freezer doors' center post had a build up of ice between the two doors, preventing it from sealing completely. The temperature was observed at 10 degrees F. and all food was frozen hard; and * The wall base next to the refrigerator was missing, exposing drywall and metal framing. The need to ensure the kitchen and equipment was kept in good repair in accordance with the Food Sanitation Rules OAR 333-150-000 was discussed with Staff 2 (Regional Director), Staff 6 (Executive Chef), and Staff 8 (Environmental Services Director) on 10/12/22. They acknowledged the findings.

Sink will be replaced by 12-11-22.  Dishwasher gauge will be repaired or replaced by 12-11-22.  Certified vendor has awknowledged that final rinse temps are reaching above 180 degrees.  Freezer to be repaired or replaced by 12-11-22.  Dry wall in kitchen was repaired on 11-2-22.  On going QA meetings to include walk-through inspection, with Executive Chef, ED and ESD monthly.

2. Resident 1 was admitted to the facility in January 2020 with diagnoses including dementia and was dependent on staff for all care. Resident 1's quarterly evaluation, dated 08/29/22, reviewed during the survey was not reflective of the resident's current needs and preferences in the following areas: * referred to use of a sling for a humerus fracture; * stated "attends meals with reminders"; * activity preferences and accommodations needed; * recent history of falls; * dressing assistance needed in relation to hip precautions; * bathing instructions for staff to follow, hospice services; * toileting needs; * hip/leg pain and current interventions; * mobility status and needs; * nutrition and hydration needs, including meal assistance; * current skin wounds; * included wandering behavior; and * evacuation assistance needs. The need to ensure quarterly evaluations were reflective of the resident's current care needs was discussed with Staff 1 (ED), Staff 3 (Health Services Director/RN) and Staff 4 (RCC) on 10/12/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#5) and failed to ensure quarterly evaluations were reflective for 3 of 3 sampled residents (#s 1, 2, and 3) whose quarterly evaluations were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 09/2022 with diagnoses including dementia. Resident 5's new move in evaluation, dated 09/07/22, and initial service plan, dated 09/17/22, were reviewed on 10/11/22. The following required elements had not been answered, were not reflective, or were missing from the initial evaluation: * Environmental factors that impact the resident's behavior including noise, lighting, and room temperature; * Skin condition; * Emergency evacuation ability; * History of weight loss or dehydration; * Elopement risk or history; * Smoking; * Presence of depression, thought disorders, behaviors, and mood; and * How the resident copes with change or challenging situations. The need to ensure new move in evaluations address all required elements  and were reflective of the residents status was discussed with Staff 1 (Executive Director) and Staff 3 (Health Services Director/RN) on 10/12/22. They acknowledged the findings. 3. Resident 3 was admitted to the facility in February 2020 with diagnoses which included dementia. Observations of the resident on 10/11/22 and 10/12/22, interviews with staff, and review of the resident's current service plan and evaluation dated 08/30/22 revealed the resident was dependent on staff for all ADL care and was a two-person transfer with a Hoyer lift. The quarterly evaluation was not reflective in the following areas: * Speech ability, the resident was primarily non-verbal; * Current skin and wound care status; * One-to-one meal assistance; * Toileting assistance needed and frequency; and * Emergency evacuation ability noted the resident would need one caregiver to exit the community in the event of an emergency with a wheelchair; however, the resident required a two-person transfer with a Hoyer lift. On 10/13/22, the need to ensure quarterly evaluations were reflective of the resident's health status, current needs and conditions was discussed with Staff 1 (ED), Staff 3 (Health Services Director/RN) and Staff 4 (RCC). They acknowledged the findings. 4. Resident 2 was admitted to the facility in 11/2020 with diagnoses including dementia. Resident 2's quarterly evaluation, dated 09/20/22, reviewed during the survey identified the following: a. The evaluation was not reflective of the resident's current needs in the following areas: * Activities, level of participation and activities of interests; * Two person repositioning while in bed; * Bathing assistance; * Outside providers noted incorrect provider information; * One to one dining assistance and preference to eat in room while in bed; * Nutrition and hydration preferences (none listed); * Ability to use call light system; * Two person fire evacuation assistance; and * Recent falls and current fall interventions were not listed. b. Resident 2's clinical record lacked documented evidence the use of a "body suit" was evaluated. The need to ensure quarterly evaluations were accurate and reflective of the resident's current care needs and interventions with potentially restraining qualities were evaluated and made part of the resident's record was discussed with Staff 1 (ED), Staff 3 (Health Services Director/RN) and Staff 4 (RCC) on 10/12/22. They acknowledged the findings.

Resident  #1, #2, #3 and #5 servcie plan to be updated by November 11, 2022 to include comprehenisve elements listed in OAR 411-054- 0034.  Ongoing auditing of initial, quarterly service plans, change of condition service plans to make sure they are comprehensive and completed timely to be done by ED, VPO and/or Regional Nurse Consultant at least quarterly. RCC, HSD and ED have completed Oregon Care Partners Webinar titled "Strategies to Prevent and Reduce Falls" on 10-24-2022.

2. Resident 5 was admitted to the facility in 09/2022 with diagnoses including dementia. On 10/10/22, Resident 5's initial service plan was requested from the facility, and could not be located. On 10/11/22 review of the service plan binders kept in the staff break room revealed no initial evaluation or service plan for Resident 5 available for staff.  In an interview at 11:10 am on 10/11/22, the Med Tech and caregiver for Resident 5 both stated there was no information available. On 10/11/22, Staff 4 (RCC) printed a new copy of the initial service plan, but acknowledged that the copy for caregivers to use was missing. The requirement that service plans must be readily available to staff was reviewed with Staff 2 (Regional Director), Staff 3 (Health Services Director/RN), and Staff 4 (RCC) on 10/11/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and preferences, readily available to staff, provided clear caregiving instructions or were followed for 4 of 4 sampled residents (#s 1, 2, 3, and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in February 2020 with diagnoses including dementia. Observations of the resident, interviews with staff, review of the clinical record and the most recent service plan dated 08/30/22, revealed the service plan was not reflective of the resident's care needs, was not followed by staff, and did not provide clear direction to staff in the following areas: * Customary routines related to getting up for meals and then going back to bed; * Home health service for wound care, including schedule; * Incontinence care provided in bed; * Repositioning throughout the day; * Foot rests to be used while in the wheelchair; * Geri sleeves to be placed on the resident in the morning and removed at night; * Shower schedule; * Right arm supported while in the wheelchair and bed; * One-to-one meal assistance; * Fluid and snack assistance between meals; and * Non-verbal indicators of pain. On 10/11/22 a review of the service plan binders kept in the staff break room revealed there was no service plan available for Resident 3. Resident 3's current service plan was requested from Staff 4 (RCC) and provided on 10/11/22. The need to ensure residents' service plans reflected current care needs, provided clear direction to staff, were available to staff and followed was discussed with Staff 1 (ED), Staff 3 (Health Services Director/RN) and Staff 4 (RCC). 4. Resident 1 was admitted to the facility in January 2020 with diagnoses including dementia. a. On 10/11/22, a review of the service plan binders for direct care staff revealed the quarterly evaluation/service plan for Resident 1 available for staff was dated 05/29/22. Upon request, Staff 4 (RCC) provided a copy of an updated evaluation/service plan, dated 08/29/22. During an interview with Staff 4, it was determined the most current service plan had not been accessible to direct care staff. b. Resident 1's service plan, dated 08/29/22, was not reflective of the resident's current status and did not provide clear instructions to staff in the following areas: * referred to use of a sling for a humerus fracture; * stated "attends meals with reminders"; * activity preferences and accommodations needed; * recent history of falls; * dressing assistance needed in relation to hip precautions; * bathing instructions for staff to follow, hospice services; * toileting needs; * hip/leg pain and current interventions; * mobility status and needs; * nutrition and hydration needs, including meal assistance; * current skin wounds; * included wandering behavior; and * evacuation assistance needs. The need to ensure service plans were accessible to direct care staff, reflective of residents current needs and provided clear directions to staff was discussed with Staff 1 (ED), Staff 3 (Health Services Director/RN) and Staff 4 (RCC) on 10/12/22. They acknowledged the findings. 3. Resident 2 was admitted to the facility in November 2020 with diagnoses including dementia. Resident 2's service plan, dated 09/20/22, was not reflective of the resident's current status, did not provide clear instructions to staff and/or staff did not follow the service plan in the following areas: * Monthly weights; * One-to-one dining assistance and preference to eat in room while in bed; * Hospice services provided bathing, incontinence care, dressing, grooming, personal hygiene and housekeeping; * Clear instructions for catheter care; * Activities, level of participation and activities of interests; * Behaviors and behavior interventions; * Two person assistance with repositioning while in bed; * Two person fire evacuation assistance; * Recent falls and current fall interventions * Use of a "body suit" lacked clear instructions that included who, when and how frequently staff were to use the body suit; and * Dietary needs to avoid lactose was not followed. The need to ensure service plans were reflective of residents' current needs, provided clear directions to staff and were followed was discussed with Staff 1 (ED), Staff 3 (Health Services Director/RN) and Staff 4 (RCC) on 10/12/22. They acknowledged the findings.

Resident's  #1, 2, 3, 4 and 5 will be reviewed by November 11, 2022 Service Plan Team that will consist of the following members at a minimum: Executive Director, Health Service Director, Resident Care Coordinator, Lifestyle Director, Resident/Responisble Party.  Other team members will be included on a Resident-by-resident basis to inculed: Caseworkers, Hospice and other Third Party Provider as appropriate.  Executive Director and/or HSD will oversee compliance by reviewing service plans.  One on one training has been done with staff and ongoing training will be done with staff re: following service plans, reading ISP's at least quarterly.  Accurately following service plans will be addressed at all staff meeting on 12-10-22.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed at least quarterly by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the residents choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 2 of 3 sampled residents (#s 2 and 3). Findings include, but are not limited to: Residents' 2 and 3 most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans. On 10/13/22, the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (ED), Staff 3 (Health Services Director/RN) and Staff 4 (RCC). They acknowledged the findings.

All service plans including Resident's # 1, 2, 3, 4 and 5 will be reviewed by Service Plan Team that will consist of the following members at a minimum: Executive Director, Health Service Director, Resident Care Coordinator, Lifestyle Director, Resident/Responisble Party by November 11, 2022.  Other team members will be included on a Resident-by-resident basis to inculed: Caseworkers, Hospice and other Third Party Provider as appropriate.  Executive Director and/or HSD will oversee compliance by reviewing service plans prior to meeting.  If Responsible Party is unable to attend, ED and/or RCC will communicate via email and/or phone and document.

2. Resident 3 was admitted to the facility in February 2020 with diagnoses including dementia. Observations of the resident, interviews with staff, review of the service plan, dated 08/30/22, temporary service plans, "wound assessment" sheets, and progress notes dated 07/13/22 through 10/07/22 were reviewed and showed the following: * An 08/12/22 progress note documented the resident had an abdominal wound to the right side that was open and bleeding. Staff had cleaned and applied triple antibiotic ointment; and * An 08/20/22 progress note documented an "opened rash on breasts, cleaned and triple antibiotic ointment was applied." The skin conditions were not documented on the wound assessment sheets provided for Resident 3. There was no documented evidence the facility evaluated the resident's skin condition, consistently monitored or determined actions or interventions specific to each change of condition at least weekly until resolved. On 10/13/22, the resident's short-term changes of condition related to skin and compliance guidelines for changes of condition and monitoring were discussed with and provided to Staff 1 (ED), Staff 3 (Health Services Director/RN) and Staff 4 (RCC). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure resident changes of condition were evaluated, resident specific interventions were determined, documented and monitored for effectiveness with weekly progress noted to resolution for 3 of 3 sampled residents (#s 1, 2, and 3) who experienced changes of condition. Resident 1 had multiple falls and sustained a hip fracture. Findings include, but are not limited to: 1 . Resident 1 was admitted to the facility in January 2020 with a diagnosis of dementia. Resident 1's clinical records revealed s/he had a history of falls with a humerus fracture in February 2022. The service plan, dated 05/29/22, identified Resident 1 as having a risk of falls and listed current interventions as "staff will need to check [him/her] frequently and when they see [him/her] awake and starting to stir, assist to get up ... safety checks 4x per shift". The record indicated Resident 1 fell on 08/04/22 while up early in the morning walking in the common area and sustained abrasions to his/her face. An Interim Service Plan (ISP), dated 08/04/22 listed fall interventions of "cue and remind resident to call for assistance ..., remind the resident to use a walker or wheelchair for mobility...". The incident and investigation reports, dated 08/04/22, did not include information on when the resident was last checked. Resident 1 experienced another fall on 08/05/22 when s/he was found face down on the floor in a hallway. The incident and investigation report, dated 08/05/22, did not include information on when the resident was last checked and did not identify any additional interventions to try and prevent falls. There was no documented evidence of new interventions being developed and implemented or a determination of the effectiveness of current interventions on the service plan following each of the falls. On 08/19/22, the record indicated Resident 1 was found on the floor in the common area and showed signs of pain and was unable to bear weight to stand. Resident 1 was sent to the hospital and diagnosed with a hip fracture. There was no documented evidence of whether the current fall interventions (assisting the resident up when awake, safety checks four times per shift) were being followed at the time of the fall and were effective, or whether new interventions needed to be developed. The facility failed to identify and document fall interventions after multiple falls and the resident sustained a hip fracture. The need to ensure changes of condition were monitored, interventions identified and implemented, and monitored for effectiveness was discussed with Staff 1 (ED), Staff 3 (Health Services Director/RN) and Staff 4 (RCC) on 10/12/22. They acknowledged the findings. 3. Resident 2 was admitted to the MCC facility in 11/2020 with diagnosis of vascular dementia. A review of the service plan, dated 09/20/22, temporary service plans, and progress notes dated 07/13/22 through 10/07/22 identified the following short-term changes of condition: * On 07/18/22 - missed medication (Spironolactone); * On 07/20/22 - missed medication (Spironolactone); * On 08/08/22 - skin tear to the right lower arm; * On 08/11/22 - skin tear to the right lower arm; * On 09/14/22 - yellowish bruise on left shin; * On 09/18/22 - scrape on right forearm; * On 09/23/22 - resident was found unresponsive; and * On 09/24/22 - resident was found unresponsive. There was no documented evidence the facility evaluated and determined what action or intervention was needed for the resident, and communicated interventions or monitoring instructions to staff. The need to evaluate and determine actions need for residents following  short term changes of condition and communicate clear instructions to staff was discussed with Staff 1 (ED), Staff 3 (Health Services Director/RN) and Staff 4 (RCC) on 10/12/22. They acknowledged the findings.

Change of Condition completed by RN for resident #1, #2, #3 by November 11, 2022.  Washington Gardens RN is enrolled in the training "The Role or RN in Community Based Care"  on December 6-8, 2022. HSD to Review Washington Gardens/ Frontier Policy about change of conditions when and how to do these by December11, 2022.  ED and RN to audit Change of Condition on a weekly basis.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had significant changes of condition were evaluated, service plan updated, and referred to the RN for 1 of 1 sampled resident (#8) who experienced unplanned significant weight loss. This is a repeat citation. Findings include, but are not limited to: Resident 8 was admitted to the facility in 02/2020 with diagnoses including advanced frontal lobe dementia. During the survey, Resident 1 was observed to receive meal cues and consumed approximately 85-100 percent of his/her meals. The most recent evaluation and service plan (dated 12/07/22) noted Resident 8's weight as 169 lbs. Between 12/07/22 (169 lbs.) and 01/01/23 (154 lbs.) s/he lost 15 lbs., or a decrease of 9 % of his/her total body weight, in 25 days. There was no documented evidence Resident 8's significant weight loss had been evaluated, referred to the facility nurse, or the service plan updated to reflect the change of condition. The facility's lack of a system in place to evaluate changes of condition, update the service plan, and refer the significant change to the RN for assessment was discussed with Staff 1 (Executive Director) and Staff 4 (RCC) on 02/27/23. They acknowledged the findings.

RN and ED to audit chart notes of residents at least weekly to monitor for change of conditions. At Daily stand up meetings residents with change of conditions or possible change of conditions will be discussed. Resident # 8 change of condition was completed on her. RN and ED to oversee and monitor

2. Resident 1 was admitted to the facility in January 2020 with diagnoses including dementia. The resident sustained a hip fracture with surgical repair in August 2022 and returned to the facility with two pressure wounds, was admitted to hospice services and required two person, mechanical lift for transfers and extensive assistance with all ADL's. The resident was observed during the survey to be non-ambulatory and required meal assistance to complete meals. The fracture and decline in mobility and ADL functioning constituted a significant change in condition. A review of the resident's clinical record, including progress notes from 08/19/22 through 10/10/22 showed an "RN note" dated 09/02/22. The RN assessment note documented the resident's admission to hospice, use of a Hoyer lift for transfers and an assessment of the wounds. However, the assessment lacked the following: * information on findings: the resident's current level of ADL ability; * interventions developed as a result of the assessment; and * evidence the service plan was updated to reflect the changes in the resident's care needs. The need for an RN assessments to include findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (ED) and Staff 3 (Health Services Director/RN) on 10/12/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure significant changes of condition were assessed by the RN and included findings, resident status, and interventions made as a result of the assessment for 2 of 2 sampled residents (#s 1 and 2) who experienced significant changes of condition. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in November 2020 with diagnoses including dementia. The resident was admitted to hospice on 07/12/22 which constituted a significant change of condition. Observations made during the survey showed staff provided full assistance with all ADL care while the resident remained in bed. There was no documented RN assessment of the significant change of condition, nor was the service plan updated to reflect the resident's changes in care needs. The need for significant change of condition RN assessments, which included findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (ED), Staff 3 (Health Services Director/RN) and Staff 4 (RCC) on 10/12/22. They acknowledged the findings.

See C270

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed for 1 of 1 sampled resident (#8) who experienced a significant change of condition related to weight loss. This is a repeat citation. Findings include, but are not limited to: Resident 8 was admitted to the facility in 02/2020 with diagnoses including advanced frontal lobe dementia. During the survey, Resident 8 was observed to receive meal cues and consumed approximately 85-100 percent of his/her meals. The most recent evaluation and service plan (dated 12/07/22) noted Resident 8's weight as 169 lbs. Between 12/07/22 (169 lbs.) and 01/01/23 (154 lbs.) s/he lost 15 lbs., or a decrease of 9% of his/her total body weight, in 25 days. The unplanned severe weight loss constituted a significant change of condition. There was no documented RN assessment completed for the weight loss which included findings, resident status, and interventions made as a result of the assessment. The need to ensure an RN assessment was completed related to significant changes in condition which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (Executive Director) and Staff 4 (RCC) on 02/27/23. They acknowledged the findings.

Weights to be audited by RN and ED at least weekly to capture and change of condtions that may be required as well as developing interventions for weight loss and weight gain as needed for residents with signficant weight loss or weight gain.

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers, ensure documentation of visits was maintained in the residents' records or that recommendations were implemented for 2 of 3 sampled residents (#s 2 and 3) who were receiving services from outside providers. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 02/2020 with diagnoses including dementia. Resident 3 was identified as receiving outside provider services related to wound care. A review of the resident's records showed on 09/26/22, home health skilled nursing provided wound care and left instructions and information for the facility that home health would visit two times per week. There was no documented evidence of outside providers' visits between 09/26/22 through 10/10/22. In an interview with Staff 3 (Health Services Director/RN) on 10/12/22, she confirmed that home health had not been leaving visit notes routinely. The need to ensure on-going coordination of care was maintained and documented was discussed with Staff 1 (ED), Staff 3 and Staff 4 (RCC) on 10/13/22. They acknowledged the findings. 2. Resident 2 received hospice services. The following recommendations for supplemental care from outside providers were not added to the resident's service plan and were not implemented: a. On 09/15/22 hospice left a written outside provider note to "please off- load bilateral heels to prevent skin breakdown." Observations made during the survey noted a box of medical supplies in the resident's room that included blue foam heel protectors. During an interview on 10/12/22, Staff 16 (MT) stated she was unaware if the resident was supposed to be wearing them. There was no documented evidence the recommendations were added to the resident's service plan. b. On 09/26/22, the resident was seen by the hospice RN due to the episodes of unresponsiveness. The hospice RN requested a change in the care plan that included new instructions for transferring from bed to wheelchair and new " monitoring" instructions during bed to wheelchair transfers. There was no documented evidence the change in care plan and new monitoring instructions were updated in the resident's service plan. The facility's failure to effectively communicate the new instructions from the outside provider and update the service plan was reviewed with Staff 1 (ED), Staff 3(Director of Health Services/ RN) and Staff 3 (RCC) on 10/12/22. They acknowledged the findings.

Residents # 2, #3 will have outside provide records requested and reviewed. Any recommendations not currently implemented will be initiated and documented within medical record by December 11, 2022. HSD and/or ED will meet with current outside providers to review protocol for exchange of information and coordination of care. Staff will be provided additional education on coordination of care with outside providers by December 11, 2022. Review of outside provider documentation will be conducted weekly during High-Risk Resident Meeting with follow-up by HSD/RCC as needed. Random chart audit for coordination of care will be conducted during QA process by Health Service Team.

Based on interview and record review, it was determined the facility failed to ensure all written, signed orders for medications and treatments from a physician or other legally recognized practitioner were carried out as prescribed for 1 of 3 sampled residents (#2) whose records were reviewed.  Findings include, but are not limited to: Review of Resident 2's 09/01/22 through 10/10/22 MAR/TAR's, weight records and signed physician orders, dated 07/12/22 and 09/28/22, identified the following orders were not carried out as prescribed: * Monthly weights; and * Fluid enhancement: Assist and encourage to drink additional eight ounces of fluid between meals and with every medication pass. Multiple observations made during the survey, which included medication pass on 10/11/22 and 10/12/22, showed staff were not consistently following the fluid enhancement order. The need to ensure all orders for medications from a physician or legally recognized practitioner were carried out as prescribed was discussed with Staff 1 (ED), Staff 3 (Health Services Director/RN) and Staff 4 (RCC).  They acknowledged the findings.

RN met with Met Techs for in-service on failing to follow POs on October 14, 2022.  For resident #2, RN and/or RCC will conduct random observations to make sure Med Techs are following the order for Fluid Enhancements.  RN and ED to review weights on a monthly basis.  During weekly Risk meeting, ED and RN to review residents with Fluid Enhancement orders and updating MAR as needed.  All staff to complete Relias, "Nutrition and Hydration - The Basics" module by December 11, 2022.

Based on observation, interview and record review, it was determined the facility failed to have a sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: 1. During the entrance conference and acuity interview on 10/10/22 the following was identified: * The memory care facility had 39 residents divided into two units; * Nine residents were identified as requiring 2-person care with transfers and/or use of mechanical lift device; * Caregivers' duties included serving meals, cleaning up after meals (floors, tables, kitchenettes), conducting daily activities and some laundry in addition to direct caregiving duties, which qualified them as "Universal Workers". Observations and interviews with staff during the survey and the facility's posted staffing plan for 10/10/22 to 10/12/22 was as follows: * During the day and swing shifts, there were four caregivers and one Medication Technician scheduled on duty; and * During the night shift, there were two caregivers and one Medication Technician scheduled on duty. The facility used an ABST (Acuity Based Staffing Tool) which determined a staffing plan. However, the facility failed to provide the number of direct caregivers as designated by the staffing tool.   Refer to C 361. 2. During the survey, a review of medication administration times for three sampled residents was completed. Medication administration times, reviewed from 10/05/22 through 10/12/22 were in excess of one hour past the scheduled administration time as follows: * Resident 1: experienced 47 medication passes that were in excess of one hour; * Resident 2: experienced 82 medication passes that were in excess of one hour; and * Resident 3: experienced 34 medication passes that were in excess of one hour. The need to ensure the facility provided enough direct care staff to meet the scheduled and unscheduled needs of the residents was discussed with Staff 1 (ED) and Staff 2 (Regional Director) on 10/13/22. No additional information was provided.

Facility to follow Acuity Based staffing tool that is currently in place.  All service plans updated by December 11, 2022 to reflect appropriate acuity of care.  Resident  #1 and #3 Service Plans to be updated by November 11, 2022. RCC, ED or RN to check tool daily to ensure adequate staffing.

Based on interview and record review, the facility failed to use the results of an acuity-based staffing tool to develop and routinely update the facility's staffing plan. Findings included, but are not limited to: Record review on 10/11/22 of the posted staffing plan, the facilities own Acuity Based Staffing Tool (ABST), the staffing schedule for 10/09/22 to 10/13/22 and service plans for Resident 1, 2 and 3 revealed the scheduled staffing plan was not reflective of the ABST. Service plans for Residents' 1, 2 and 3 were not reflective of the residents care needs and the acuity tool, therefore, did not accurately measure the residents care needs. In an interview on 10/11/22 with Staff 2 (Regional Director) and on 10/12/22 with Staff 1 (ED) and Staff 4 (RCC) it was determined the facility had not been scheduling the number of direct care staff as determined by the ABST. In addition, service plans were required to be updated to be included in the ABST tool staffing plan. The need to ensure a staffing plan was generated by the ABST, included accurate resident information and was followed was discussed with Staff 1, Staff 2 and Staff 4. They acknowledged the findings.

See C 360.

The Department imposed a condition on the facility on 12/02/22 and issued a continuance for the condition on 02/23/23. The facility has been working with the Department to resolve the condition. They remain out of compliance with C 361 until the condition is lifted.

ED, HSD and RCC to review Service Plans on a weekly basis for accuracy and that you will run the ABST report daily for review with the Staffing team.

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, and fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to: Fire and life safety records, reviewed for the period between 04/2022 and 10/10/2022, revealed the following: 1. The facility failed to relocate or evacuate residents during fire drills; and the  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 * The number of occupants evacuated. 2. Fire and life safety instruction was not consistently provided to staff on alternate months. The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (Executive Director) and Staff 8 (Environmental Services Director) on 10/12/22. They acknowledged the findings.

a Fire and Life Safety training was conducted with all-staff on October 12, 2022.  ED and ESD will ensure calendar remindes in TELS platform for an every-other-month All Staff. Emergency Disaster Orientaton will be reviewed with all residents by December 11, 2022.  ED to conduct periodic audits to ensure this is being done per admission and annually. Evacuation Fire Drill conducted on October 11, 2022.  ED and ESD will ensure calendar remiders in TELS platform for alternating month Fire Drills.

Based on interview and record review, it was determined the facility failed to ensure residents who can follow instructions received instruction at admission and re-instruction in fire and life safety training, at least annually after admission. Findings include, but are not limited to: Fire and life safety records were requested during the survey. The following deficiencies were identified: There was no documentation that residents who were able to follow instructions were provided with fire and life safety training at admission, or fire and life safety training at least annually following admission. The need to ensure residents who could understand instructions receive fire and life safety instructions at admission, and annual re-instruction was discussed with Staff 1 (Executive Director) and Staff 3 (Health Services Director/RN). They acknowledged the findings.

Emergency Disaster Orientaton will be reviewed with all residents by December 11, 2022.  ED to conduct periodic audits to ensure this is being done per admission and annually.

3. Resident 5 was admitted to the facility in September 2022 with a diagnosis of dementia. Observations during the survey from 10/10/22 through 10/12/22, showed Resident 5 was not able to obtain food or fluids for themselves due to cognitive impairment and relied on staff. Resident 5's service plan, dated 09/20/22, lacked individualized information.  The section for diet and nutrition documented the resident did not have any food likes or dislikes and could self select all food and beverage choices. An interview on 10/11/22, Resident 5's family provided information about food preferences and dietary needs that were not documented on the service plan. The need for individualized nutrition and hydration plans was discussed with Staff 1 (ED) and Staff 4 (RCC) on 10/12/22.  They acknowledged the findings. 4. Resident 3 was admitted to the facility in February 2020 with diagnoses including dementia. Resident 3's 08/30/22 service plan instructed staff to provide snacks and fluids throughout the day. Observations of meals on 10/11/22 and 10/12/22 identified the resident needed full assistance from staff with eating and drinking. The resident was not observed to be provided snacks or fluids between the morning and noon meals. The need to ensure the facility implemented and followed residents' individualized nutritional plans was discussed with Staff 1 (ED), Staff 3 (Health Services Director/RN) and Staff 4 (RCC) on 10/13/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure individualized nutrition and hydration plans were developed, followed and included in the service plan for 4 of 4 sampled memory care residents (#s 1, 2, 3, and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in January 2020 with diagnoses including dementia. During observations of the resident on 10/10/22 through 10/12/22, it was revealed the resident was dependent on staff to attend meals, used a geri-chair for positioning during meals, required assistance from staff to complete eating meals, needed assistance to drink liquids and was dependent on staff for snacks and hydration. Resident 1's service plan, dated 08/29/22, had no individualized hydration and nutrition plan identified for the resident. The service plan did not include clear instructions to staff for ways to meet the resident's nutrition and hydration needs. The need for individualized nutrition and hydration plans was discussed with Staff 1 (ED) and Staff 2 (RCC) on 10/12/22.  They acknowledged the findings. 2. Resident 2 was admitted to the MCC facility in November 2020 with a diagnosis of dementia. Resident 2 was admitted to hospice on 07/12/22. Resident 2's service plan, dated 09/20/22, lacked staff instructions or was not followed related to the resident's individual nutritional and hydration needs. Observations during the survey from 10/10/22 through 10/13/22, revealed Resident 2 was unable to obtain food or fluids for him/herself due to cognitive impairment. Staff were not observed to consistently follow Resident 2's physician orders to provide fluid enhancement between meals and with every medication pass. During an interview on 10/12/22, Staff 12 (CG) reported "snacks were passed between meals, the first snack pass is usually around 10 am and again before the end of my shift [2:00 pm]." On 10/11/22, the scheduled snack pass after lunch was not completed and on 10/12/22, the scheduled snack pass after breakfast was not completed. The need for individualized nutrition and hydration plans was discussed with Staff 1 (ED) and Staff 3 (Health Services Director/RN) and Staff 4 (RCC) on 10/12/22. They acknowledged the findings.

Residents with specialized hydration and nutrition plans will have service plans reviewed, with ISP or handwritten changes that are initialed and dated implemented for any hydration and nutrition plan needs not addressed in service plan by December 11, 2022.  Changes to be fully incorporated into service plans with next comprehensive service plan ( quarterly or change of condition) Residents #1,2,3 and 5 will have service plans updated to reflect hyrdation and nutrition needs. Staff to be educated on hydration and nutrition and inclusion of specialized hydration and nutrition needs on November 10, 2022.  Staff to complete Relias module "Nutrition and Hydration - The Basics" by December 11, 2022. ED and/or HSD to review Service Plans upon completion to ensure they reflect the specialized hydration and nutrition needs of residents (as needed) on an ongoing basis. Random SP audits to be conducted by Health Services Department during QA process at least monthly.

Based on observation, interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 4 of 4 sampled residents (#s 1, 2, 3 and 5) whose service plans were reviewed. Findings include, but are not limited to: Residents 1, 2, 3 and 5's service plans offered information relating to the resident's past interests; however, the facility had not thoroughly evaluated the following: * Current interests; * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Identification of activities for behavioral interventions. Observations of the residents from 10/10/22 through 10/12/22 revealed the lack of activity programs that included the residents in one to one or group interaction. There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the residents with individualized activities. The lack of an activity evaluation and individualized activity plan was discussed with Staff 1 (ED) and Staff 5 (Life Enrichment Director) on 10/13/22. They acknowledged the findings.

Residents #1, 2, 3, and 5 will have Service Plans updated in the following areas:  Current abilities and skills, Emotional and social needs and patters, Physical abilities and limitations, adaptions necessary for the resident to participate, and Activities that could be used as behavioral interventions by November 11, 2022.  Individualized.  Individualized Activity Plans to be developed for each resident by December 11, 2022 and will include in Service Plan. Staff to be educated on individual Activity Plans and utilization of these plans by December 11, 2022.  ED and RN to review Service Plans upon completion to ensure they reflect individualized Activity Plan. LEC to conduct monthly Servce Plan audits.

Resident 5 was admitted to the facility in September 2022 with the diagnosis of dementia. Resident 5's record documented behaviors including: * Directing profanity toward staff and residents; * Exit seeking; * Sexual behaviors toward and statements to other residents; and * Threatening caregivers with violence. Observations on 10/10/22 and interviews revealed staff did not have access to a copy of Resident 5's service plan.  The survey team requested a copy of the service plan, and Staff 4 (RCC) provided a copy. The current service plan lacked individualized interventions to assist staff in minimizing the negative impact of the behaviors. On 10/12/22, the need to develop individualized behavior plans for residents with behavioral symptoms and provide the information to staff on all shifts was discussed with Staff 1 (Executive Director) and Staff 2 (Director of Health Services/RN). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide and update an individualized service plan for behavioral symptoms that negatively impacted the resident or others in the community for 2 of 2 sampled residents (#s 2 and 5) with documented behaviors. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 11/2020 with diagnoses including vascular dementia and chronic urinary tract infections. A review of Resident 2's record and interviews with staff noted behaviors related to pulling on the catheter and "fecal smearing". The resident's service plan, dated 09/20/22, referenced behaviors related to pulling out his/her catheter and "fecal smearing". The service plan further noted Resident 2 wore a body suit to reduce the frequency of the behaviors. Observations and interview with Resident 2 on 10/12/22 noted the resident was not wearing the body suit and was pulling at the catheter tubing. In an interview with Staff 16 (MT) on 10/12/22 it was reported all his/her body suits were in the laundry. Staff 16 was unaware of any other interventions for redirecting or minimizing the resident's behavior. The service plan lacked clear instructions for staff on the use of the body suit; when to assist the resident to wear it, when it should be removed, risks and what to report, and lacked effective interventions to attempt prior to the use of the body suit. The need to ensure resident's with known behaviors have an  individualized behavior plan was discussed with Staff 1 (ED), Staff 3 (Health Services Director/RN) and Staff 4 (RCC) on 10/12/22. They acknowledged the findings.

Residents including resident's # 2 and 5 with known behaviors will have service plans reviewed and updated as needed to reflect behaviors and individualized interventions to minimize or mitigate the potential negative outcome from these behaviors by November 11, 2022. Staff to be provided education on utilization of service plans for minimizing and/or mitigation strategies for behaviors by November 10, 2022. ED and/or HSD to review service plans prior upon completion to ensure they reflect the individualized intervention for behaviors on an ongoing basis.  Random Service Plan audits to be conducted by Health Service Team for QA process at least monthly.

Based on observation, interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to Z 142, Z 162, C 270 and C 280.

No POC needed per DHS

Based on interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 361.

No plan of correction needed per DHS

Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 270 and C 280.

No plan of correction needed per DHS

The findings of the re-licensure survey, conducted 10/10/22 through 10/13/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first re-visit survey to the re-licensure survey of 10/13/22, conducted 02/22/23 through 02/28/23, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Regulations. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the second revisit to the re-licensure survey of 10/13/22, conducted 06/20/23 through 06/21/23, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.