Murray Highland

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 report injuries of unknown cause to the local Department office unless an immediate facility investigation reasonably concluded and documented that the physical injury was not the result of abuse, for 1 of 1 sampled resident (# 2) who had injuries of unknown cause. Findings include but are not limited to: Resident 2 moved into the MCC in 03/2022 with diagnoses including Alzheimer’s disease. Review of the resident's clinical record, including progress notes from 12/11/25 through 03/11/26, identified the following: * The 03/03/26 service plan indicated Resident 2 experienced expressive aphasia (impaired ability to speak) that severely limited his/her ability to communicate verbally with staff. The service plan noted the resident was “not always able to communicate [his/her] needs” nor had the ability to “understand a conversation.” * 12/19/25 – In a charting note, a Temporary Service Plan (TSP) noted, “Resident has a skin tear to [his/her] left elbow”; * 12/22/25 - In a charting note, a TSP noted, “Resident seems to have developed a skin tear in [his/her] upper right wrist with no bleeding but is very red”; and * 03/01/26 – In a charting note, a TSP noted, “Make sure to monitor [his/her] bruise and skin tear on [his/her] right toes for any changes or improvements.” These skin tears and bruise represented injuries of unknown cause which were required to be reported to the local Department office unless an immediate facility investigation reasonably concluded and documented the physical injury was not the result of abuse. During an interview on 03/13/25 at 1:20 pm, Staff 1 (ED) confirmed the above injuries were not investigated. The facility failed to immediately investigate injuries of unknown cause and report the injuries to the local Department office if an immediate investigation was not completed. The need to ensure all injuries of unknown cause were immediately investigated to rule out suspected abuse and were reported to the local Department office if abuse could not be ruled out, was discussed with Staff 1 on 03/13/26 at 3:55 pm. He acknowledged the findings. Survey requested the facility report the above incidents to the local Department office. Confirmation that the incidents were reported was received on 03/16/26 at 3:08 pm.

1- Resident #2, has been reviewed and the requested self-reports have been completed. 2- All care staff, med-techs and supervisors have been re-educated that any injury of unknown cause must be reported immediately to the med-tech, RCC, RN or Administrator before the end of the shift and documented on the community incident report (August health). During daily stand-up and shift-to-shift communication, staff are reminded that injuries of unknown cause, require prompt reporting and investigation. Management reviews all incident reports daily to ensure that injuries of unknown cause are identified, investigated timely, and abuse or neglect is ruled out. If abuse and neglect cannot be ruled out, the report will be submitted to APS per OAR requirements. 3- This system will be reviewed weekly with the management team to ensure that it is in compliance. Any findings will be brought to the Quality Assurance Committee for additional review and corrections. 4- The Administrator will be responsible for compliance.

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 available to staff, reflective of residents’ care needs, provided clear instruction to staff regarding the delivery of services, and were implemented for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the MCC in 12/2025 with diagnoses including dementia and history of falls. Resident 1’s service plan, dated 03/11/26, and temporary service plans (TSPs), dated 12/11/25 through 03/11/26, were reviewed, observations were made, and interviews with staff and the resident were conducted. a. On 03/11/26 during the acuity interview, staff reported current service plans were kept in a service plan binder located in the “pass through hallway”; however, Resident 1’s service plan was not observed in the service plan binder. At 3:58 pm, staff provided a service plan dated 12/11/25 and reported it was in the locked MT room. On 03/11/26 at 5:00 pm, the residents’ current service plan, dated 03/11/26, was provided; however, it was not available to staff. The facility failed to ensure current service plans were available to staff. b. The service plan was not reflective of the resident’s care needs and lacked clear instruction to staff in the following areas: * Interventions for behaviors that included yelling and agitation when other residents entered his/her room or were near the door to his/her room; and * Preference to keep the door to his/her room open. Throughout the survey, staff were observed to close the door to Resident 1’s room. On 03/12/26 at 10:45 am, Resident 1 was in his/her room when an unsampled resident was observed entering the room. Resident 1 became visibly agitated and yelled at the unsampled resident to get out. Resident 1 reported the unsampled resident “…comes here all the time, appears nice but [s/he] is mean” and voiced the desire to keep his/her door open so s/he does not “…miss out on what’s going on in the world.” Interviews with Staff 4 (RCC), Staff 9 (CG), and Staff 10 (CG) during survey, between 03/11/26 and 03/13/26, confirmed Resident 1 did not like his/her door closed and became agitated by other residents’ going into his/her room or being near his/her door. The need to ensure service plans were available to staff, were reflective of residents’ care needs, and provided clear instruction to staff regarding the delivery of services was discussed with Staff 1 (ED) on 03/13/26 at 4:30 pm. He acknowledged findings. 2. Resident 2 moved into the MCC in 03/2022 with diagnoses including Alzheimer’s disease. a. On 03/11/26 during the acuity interview, staff reported current service plans were kept in a service plan binder located in the “pass through hallway”; however, Resident 2’s service plan was not observed in the service plan binder. At 3:58 pm, staff provided a service plan dated 11/06/26 and reported it was in the locked MT room. On 03/11/26 at 4:30 pm, the residents’ current service plan, dated 03/03/26, was provided; however, it was not available to staff. The facility failed to ensure current service plans were available to staff. b. The 03/03/26 service plan was not reflective of the resident’s current care needs, lacked clear instruction, and was not implemented in the following areas: * Use of a Hoyer device, including which colored loops on the sling to use, where the resident should place their hands, and the reclined position of the wheelchair; * Skin integrity, including multiple areas of breakdown; * Aspiration precautions, including remaining upright for 30 minutes after eating; * Positioning when in wheelchair for protection of skin, including removal of sling and cushion behind legs; and * Use of fall mat when in bed. Observations during the survey showed the resident used a Hoyer device to transfer, and the caregiver provided instruction to another caregiver on which colored loops to use when connecting the sling to the Hoyer. Additional observations showed the back of the resident’s wheelchair was reclined during a transfer into the chair, and a cushion was placed behind his/her legs as protection. On 03/12/26 Resident 2 was assisted back to bed and did not remain upright for 30 minutes after finishing his/her lunch. During an interview on 03/12/26 at 10:40 am, Staff 10 (CG) indicated the fall mat was used for protection in case the resident fell out of bed. The need to ensure residents’ current service plans were readily available to staff, were reflective of the resident’s status and care needs, provided clear instruction to staff regarding the delivery of services, and were implemented was reviewed with Staff 1 (ED) on 03/13/26 at 3:55 pm. He acknowledged the findings.

1- A 100% audit has been completed to ensure that all resident service plans are available for staff review and sign offs, and located in the "Pass through hallway". Resident # 1 has had their service plan reviewed and corrections made to address the residents care needs, to include interventions for behaviors, including yelling and agitiation and preferences for the residents door to be open. Resident #2's service plan has been reviewed, updated and is currently in the Service Plan Binder, and has been updated to reflect the residents needs. This is to include the use of the Hoyer device for transfers, and the use of the colored straps, the skin integrity, aspiration precautions and positioning when in the wheelchir for the protection of the skin, to include sling removal and the use of cushion behind the legs, and the use of the fall bed next to bed. 2- New admissions, returns from hospital, temporary service plans (TSPs) and changes of condition will be reviewed daily during stand up to ensure service plans are current, reflective of the residents needs, and contain clear staff instructions for care delivery. Random care observations will be conducted to ensure staff are implementing the service plan as written. Any gaps identified will result in immediate service plan updates and staff re-education. Clinical team will review findings routinely to ensure ongoing compliance and accuracy. 3- This system will be audited weekly by the management team to ensure compliance. Any findings will be brought to the Quality Assurance Committee for additional review and corrections. 4- The Clinical Director and the RCC will be responsible for compliance.

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 communicate determined actions or interventions to staff, document weekly progress through resolution, and monitored each resident consistent with his or her evaluated needs and service plan for 2 of 2 sampled residents (#s 1 and 2) who experienced short-term changes of condition. Resident 2 had a heel wound that became infected. Resident 1 experienced severe, ongoing weight loss. Findings include, but are not limited to: 1. Resident 2 moved into the MCC in 03/2022 with diagnoses including Alzheimer’s disease. During the acuity interview on 03/11/26 at 2:25 pm, Resident 2 was identified as having a heel wound, needing a two-person assist with mobility and ADL care, and receiving hospice services. A review of Resident 2’s clinical record, from 12/11/25 through 03/11/26, revealed the following: * The resident’s 03/03/26 service plan indicated the resident “recently experienced a series of skin integrity/breakdown issues” that was followed by hospice and the facility RN, and s/he needed to be out of bed for no more than an hour/day per hospice recommendation to promote healing of skin breakdown areas. * A hospice note dated 12/17/25 instructed staff to “use foam booties to protect feet and ankles from skin breakdown” and a 12/18/25 TSP communicated the information to staff. * A hospice note dated 12/24/25 indicated, “DTI [deep tissue injury] medial R [right] heel.” A physician communication dated 12/24/25 provided wound care instructions for the heel wound, noting the facility was to change the dressing if there was “soilage or dislodgement,” to notify hospice with signs of infection, and the hospice nurse would change the dressing two times per week. The physician instructions for PRN dressing changes were noted on the MAR and did not provide additional information on the status of the wound. There was no documented evidence the resident had been placed on alert and monitored for the right heel wound. * A 12/26/25 Temporary Service Plan (TSP) instructed staff to float the resident’s heels and keep pressure off his/her feet. * A hospice note dated 12/30/25 indicated DTI to right heel “appear to have resolved.” However, three days later, on 01/02/26, hospice noted “dressings on R heel … changed. Both wounds slowly improving.” On the same day, Staff 2 (Facility RN) completed a weekly significant change of condition note regarding resident’s additional skin conditions and a pressure wound in another location but made no mention of the right heel wound or its status. * Eleven days after the status of the heel wound was last documented, on 01/19/26, a hospice noted indicated, “No dressing on R heel again wound [sic] larger with darker center . . . Please keep heel dressing in place.” A note from Staff 2, dated 01/20/26, documented the resident had a “dry and intact dressing to [his/her] right heel . . . will continue to monitor with weekly skin assessment.” This was the first documented evidence the right heel wound had been addressed by Staff 2. * A hospice note dated 01/23/26 indicated, “Continue to monitor heel.” However, no additional information was provided regarding the status of the wound. * On 01/29/26, ten days after the wound was documented as worsening, Staff 2 completed a weekly skin assessment but there was no information about the current status of the right heel, including the size of the wound. * Eleven days later the wound was noted as worsening and on 01/30/26, a hospice note indicated the right heel wound measured 1 cm (centimeter) by 1 cm. * On 02/13/26, 02/19/26, and 02/26/26, Staff 2 documented a weekly skin assessment addressing a different wound but there was no information regarding the right heel wound or its current status. Hospice visits were made between 02/02/26 and 03/01/26; however, there was no documented evidence on the status of the wound. * On 03/01/26, 27 days from the last documented evidence on the status of the right heel wound, the resident was put on alert charting by the MT for his/her right heel due to “discharge of puss [sic] and blood noted, no odor.” The charting notes indicated, “Hospice, RCC, and CRN [facility RN] were notified.” On 03/03/26 the wound had “leaks and the bandage was full of puss [sic],” and the MT cleaned the wound. There was no documented evidence the resident’s wound had been evaluated by the facility RN or the hospice nurse. * Day shift charting notes on 03/04/26 indicated the right heel wound had “developed odor” with ongoing pus and blood and “appeared to be getting deeper and burrowed in the surrounding skin.” After reading the note documented earlier that day, an overnight MT noted hospice was contacted. * On 03/05/26, Staff 2 documented a weekly skin assessment and noted Resident 2 had an “open wound” to the right heel, which had an odor and small amount of pus-like drainage. She noted the wound measured 3 cm by 2.5 cm and had “a ring of dark peri wound skin [surrounding the wound].” She indicated the hospice nurse assessed it and “looks like [the resident] needs an antibiotic for the wound.” Resident 2 was noted to have a right heel wound which worsened, became infected, and required a seven-day course of antibiotics, completed on 03/12/26. The facility failed to monitor the progress of the wound, at least weekly, and the wound became infected. Observations of the resident during the survey identified a dressing on his/her right heel, heel booties were worn in bed and when up in the wheelchair, and staff were repositioning the resident in bed using pillows. A caregiver was observed changing the resident’s right heel dressing on 03/12/26 after it became partially dislodged. On 03/12/26 at 10:52 am, Resident 2’s right leg was observed hanging off of his/her bed, without the right heel protector bootie, and his/her heel was resting against the side of the bed. During an interview at 2:43 pm on 03/12/26, Staff 2 acknowledged she was responsible for completing the weekly skin assessments. During an interview at 3:55 pm on 03/13/26, Staff 1 (ED) acknowledged the right heel wound was not monitored weekly in the RN’s weekly skin assessments and confirmed the resident was on antibiotics for the infected wound. The need to ensure the facility monitored short-term changes of condition, with progress noted at least weekly, was discussed with Staff 1 on 03/13/26 at 3:55 pm. He acknowledged the findings. 2. Resident 1 moved into the MCC in 12/2025 with diagnoses including dementia and a history of falls. During the acuity interview on 03/11/26 at 2:25 pm, Resident 1 was identified as having had significant weight loss, a fall with fractures, a hospitalization, and a recent decline. A review of Resident 1’s clinical record, between 12/11/25 and 03/11/26, revealed the following: Resident 1’s recorded weights were as follows: * 12/13/25 - 105.5 pounds; * 01/10/26 - 99.0 pounds; * 02/10/26 - 92.4 pounds; and * 03/10/26 - 88.0 pounds. Between 12/13/25 and 01/10/26 the resident experienced a weight loss of 6.5 pounds, or 6.16% of his/her total body weight, in 30 days. On 01/13/26 an RN assessment was completed with a documented intervention to encourage the resident to eat his/her meals. However, there was no documented evidence the determined interventions were communicated to staff on each shift or implemented. An RN follow-up assessment was completed on 01/29/26 for significant weight loss, which indicated the resident had lost 4.6 pounds since 01/21/26. The documented interventions noted were previously identified on the 01/13/26 assessment, and there was no documented evidence they were communicated to staff, that the resident was monitored consistent with his/her evaluated needs, or that the interventions were implemented. A 02/03/26 RN follow-up assessment for the significant weight loss indicated the resident had lost another pound in one week. In addition to the previously documented interventions, additional interventions were to encourage the resident to go to the dining room for meals and offer frequent snacks. However, there was no documented evidence previous interventions or the new documented interventions were communicated to staff or implemented. On 02/07/26 the facility received a physician’s order to arrange a dietician consult; however, there was no documented evidence the facility communicated the intervention to staff. On 03/13/26 at 4:30 pm, Staff 1 (ED) confirmed the dietician consultation was not implemented. Between 01/10/26 and 02/10/26, the resident experienced another weight loss of 6.6 pounds, or 6.60% of his/her total body weight, in 30 days. An RN assessment was completed on 02/13/26 for the continued weight loss and noted the resident did not appear to be gaining weight. In addition to the previously documented interventions from the 02/03/26 RN Assessment, the RN added meal monitoring to the MAR. There was no documented evidence the prior interventions identified were communicated to staff or were monitored consistent with the resident’s evaluated needs. Between 12/13/26 and 03/10/26, the resident experienced a total weight loss of 17.5 pounds, or 16.5% of his/her total body weight, in 90 days. Resident 1 experienced a severe weight loss on 01/10/26. There was no documented evidence the facility consistently communicated the determined interventions regarding the weight loss to staff and monitored the resident according to his/her evaluated needs. The resident continued to lose weight. During the survey the following was observed: * For breakfast on 03/12/26, Resident 1 was observed eating scrambled eggs, sausage, biscuits, fruit cocktail, and apple juice, and s/he consumed about 50% of the meal. S/he complained of feeling sick and nauseous and went back to bed. The MT provided Resident 1 with medication for gas. * For lunch on 03/12/26, Resident 1 was observed eating meatloaf, potatoes, green beans, a cookie, water, and juice, and s/he consumed about 50% of the meal. On 03/13/26 at 2:30 pm, Staff 4 (RCC) confirmed there was no documented evidence that temporary service plans were created for weight loss interventions after each RN assessment. During an interview on 03/13/26 at 4:30 pm, Staff 1 acknowledged the interventions were not consistently communicated to staff, implemented and monitored. The need to ensure the facility communicated determined actions or interventions for changes of condition to staff on each shift and monitored each resident consistent with his or her evaluated needs and service plan was reviewed with Staff 1 on 03/13/26 at 4:30pm. He acknowledged the findings.

1-Resident # 1 has been reassessed by another RN and her weight variances and interventions have been reviewed for effectiveness and will be followed weekly to establish her new baseline. Care staff instructions have been reviewed with the care staff for implementation. Resident # 2 identified in the survey- these wounds have resolved. 2- All residents have been reviewed by the clinical team to determine if there are any short or long term changes of condition. The RN and RCC will meet weekly to review the clinical dashboard and the resident's conditions to determine if any triggers have been identified, this is to include monthly weight variance reports and skin conditions (weekly assessments to be completed & to include treatment regime effectiveness). 3- This system will be evaluated weekly to ensure compliance by the RN. Any areas identified will be reviewed in the Quailty Assurance Committee for system changes as needed. 4- The RN will be responsible for compliance.

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 interview and record review, it was determined the facility failed to ensure a significant change of condition assessment was completed by the RN, which included findings, resident status, and interventions, for 1 of 1 sampled residents (# 2) who experienced a significant change of condition for a pressure ulcer. Findings include, but are not limited to: Resident 2 moved into the MCC in 03/2022 with diagnoses including Alzheimer’s disease. Resident 2’s clinical record was reviewed from 12/11/25 through 03/11/26 and revealed the following: An RN hospice note, dated 12/24/25, indicated Resident 2 had a “stage 2 medial R [right] great toe” pressure wound. During an interview on 03/13/26 at 2:15 pm, Staff 1 (ED) acknowledged there was no RN assessment completed which documented findings, resident status, and interventions made as a result of the assessment. The need to ensure an RN assessment was completed for residents who experienced significant changes of condition was discussed with Staff 1 on 03/13/26 at 3:55 pm. He acknowledged the findings.

1- Resident # 1 identified in the survey has been re-assessed for changes to his condition. A new significant change of condition has been initiated by a new RN and will be followed weekly until stabilized at baseline. 2- When a resident experiences a significant change of condition (short or long term conditions), the RN will complete and document a comprehensive nursing assessment that includes the resident’s current status, assessment findings, changes from baseline, contributing factors, and interventions initiated. The RN assessment will also include follow-up actions such as service plan updates, physician and family notification as appropriate, monitoring frequency, and evaluation of intervention effectiveness. The RN will continue to reassess the resident until stabilization or a new baseline is established. All residents have been reviewed by the clinical team, RN and RCC to review the clinical dashboard and residents conditions to determine if any triggers have been identified, this is to include monthly weight variance reports and skin condition. 3- This system will be evaluated weekly to ensure compliance by the RN. Any areas identified will be reviewed in the Quailty Assurance Committee for system changes as needed. 4- The RN will be responsible for compliance.

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 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs.

Based on interview and record review, it was determined the facility failed to ensure staff were informed of new interventions recommended by outside providers and the service plan was adjusted, if necessary, for 2 of 2 sampled residents (#s 1 and 2) who received hospice and home health services. Findings include, but are not limited to: 1. Resident 1 moved into the MCC in 12/2025 with diagnoses including dementia and a history of falls. The resident's clinical record, from 12/11/25 through 03/11/26, was reviewed, and staff were interviewed. The following was identified: Resident 1 began receiving home health services after a fall resulting in rib fractures. The following transcriptions of the outside provider recommendations were identified in the residents’ progress notes: * 01/11/26: One staff assist for all mobility and to walk three times daily with a walker and staff assist; * 01/20/26: One staff assist for all mobility secondary to safety; * 01/28/26: Continue with assistance of one staff for mobility and noted when the resident ambulated short distances his/her blood oxygen levels dropped and indicated the resident may benefit from a medication review; and * 02/24/26: Continue assistance of one staff for all mobility and noted the resident had progressive weakness. Documentation revealed staff reviewed the above recommendations; however, there was no documented evidence direct care staff were informed of the recommendations or that the service plan was adjusted. In an interview on 03/13/26 at 4:30 pm, Staff 1 (ED) confirmed the interventions recommended by the outside provider were not communicated to staff, and the service plan was not updated. The need to ensure staff were informed of new interventions and the service plan was adjusted as necessary after outside provider services were provided was discussed with Staff 1 on 03/13/26 at 4:30 pm. He acknowledged the findings. 2. Resident 2 moved into the MCC in 03/2022 with diagnoses including Alzheimer’s disease. Resident 2’s clinical record from 12/11/25 through 03/11/26 was reviewed, including outside provider notes. There was no documented evidence staff were informed of new instructions and the service plan was updated, as necessary, for the following recommendations: * 12/19/25: A hospice RN documented “Instructions for the care team: Please encourage fluid. Offer every 2 hours while awake if possible”; * 12/27/25: A hospice nurse instructed staff to “ensure patient is able to swallow food properly”; and * 02/02/26: A hospice nurse identified “stage 1 circular wound to right ankle . . . reposition to keep pressure off right ankle.” During an interview with Staff 4 (RCC) on 03/13/26 at 11:50 am, she confirmed there was no documented evidence the hospice instructions were communicated to staff. The need to ensure staff were informed of new interventions and the service plan was adjusted as necessary after outside provider services were provided was discussed with Staff 1 (ED). He acknowledged the findings.

1- The residents identified in the survey (resident #1 & #2) have had their medical records reviewed by the clinical team to ensure that all of the communications received from their outside prviders has been collated to ensure that there is a comprehensive service plan that reflects coodination of care. 2- A community wide audit has been completed to have a master list of outside providers for the residents. This list will be updated as services change. All Outsider Provider Forms will be collected with each provider visit and reviewed daily in the clinical meetings. Any changes, recommendations or other directions will be transferred to a TSP for communication to staff. This process will be reviewed weekly by the RN and RCC for compliance. 3- This process will be evaluated weekly for compliance. 4- The RN & RCC will be responsible for the compliance.

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs.

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 for 2 of 2 sampled residents (#s 1 and 2) who received ADL care and meal delivery in the room. Findings include, but are not limited to: 1. Resident 1 moved into the MCC in 12/2025 with diagnoses including dementia and was noted to receive meal service in his/her room. Observations were made, from 03/11/26 through 03/13/26, to determine adherence to universal precautions for infection control. a. During ADL observations on 03/12/26 at 12:54 pm, the following was noted: * Staff 12 (Housekeeper/CG) exited Resident 2’s room with disposable gloves on her hands and did not doff the gloves prior to entering Resident 1’s room; * Staff 12 assisted Resident 1 with his/her bedding, turned off the call light, exited Resident 1’s room, and re-entered Resident 2’s room without doffing the gloves or completing hand hygiene; and * Staff 12 exited Resident 2’s room, doffed the gloves in the hallway, put the potentially contaminated gloves in her pocket, and entered another resident’s room. b. During meal service observations on 03/12/26 and 03/13/26, Staff 12 delivered Resident 1’s meal to his/her room uncovered, which created the potential for contamination. The facility failed to maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment. The need to ensure universal precautions for infection control were exercised, during meal delivery and before and after ADL care, was discussed with Staff 1 (Executive Director) on 03/13/26 at 4:30 pm. He acknowledged the findings. 2. Resident 2 was admitted to the MCC in 03/2022 with diagnoses including Alzheimer’s disease. Observations were made, from 03/11/26 through 03/13/26, to determine adherence to universal precautions for infection control. The following was identified: a. On 03/12/25 at 10:52 am, the surveyor observed two staff provide incontinence care for Resident 2 in bed and personal hygiene once the resident was sitting in the wheelchair. Both staff donned gloves, without first performing hand hygiene. One caregiver determined the resident’s brief was dry and applied barrier cream to the buttocks, then removed the glove used to apply the barrier cream. Without performing hand hygiene, she donned a clean glove. The same caregiver proceeded to remove the resident’s dislodged heel wound dressing, used wound cleansing spray, dabbed the wound with gauze, and put on a fresh dressing. With the same soiled gloves, the caregiver assisted the resident with donning his/her shirt, cleaned the underarm skin with a washcloth, and touched the Hoyer and sling, wheelchair, cushion for behind the legs, and the toothbrush head. The caregiver removed her gloves and washed her hands. There was no evidence the second caregiver changed her gloves between dirty and clean tasks. b. On 03/12/26 at 12:48 pm, the surveyor observed two staff perform incontinence care after transferring the resident back to bed. Staff 2 (Facility RN) was also present to obtain wound care measurements of the coccyx and heel wound. Two staff were observed donning gloves without first performing hand hygiene. Once the resident was in bed on his/her side, both staff began to remove the soiled brief. One staff left the room to answer Resident 2’s call light, Staff 2 remained to assist Resident 1 and provided peri care with disposable wipes. Staff 2 handed the caregiver the soiled wipes, which she placed on the nightstand, and then the soiled brief, which the caregiver placed on the floor, not in a trash receptacle. The second caregiver returned to the room. There was no observation of either caregiver performing hand hygiene after re-entering the resident room and/or prior to touching the resident’s clean brief, pillows, draw sheet, heel protectors, sling, bed controller, sheet, blanket, and fall mat. The facility failed to maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment. The need to ensure infection prevention and control protocols were followed was discussed with Staff 1 (ED) on 03/13/26 at 3:55 pm and he acknowledged the findings.

1- Resident # 1 & # 2 have been reassesssed by the RN and have not had negative effects based on the lack of infection control practices by care staff. 2- Re-training has been provided to all care staff regarding the need to follow handwashing, proper glove donning and doffing, and touching of contaminated surfaces, to include proper disposal of contaminated products, and proper delivery of meal services. 3- Random one on one observations will be conducted to the care staff to ensure compliance. This system will be evaluated weekly to ensure compliance by the RN & RCC. Any areas identified will be reviewed in the Quailty Assurance Committee for system changes as needed. 4- The RN & RCC will be responsible for compliance.

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 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed and the facility had written, signed physician or other legally recognized practitioner orders documented in the resident's facility record for all medications the facility was responsible to administer for 2 of 2 sampled residents (#s 1 and 2) who were administered medications. Findings include, but are not limited to: 1. Resident 1 moved into the MCC in 12/2025 with diagnoses including dementia and a history of falls. The resident’s physician orders, dated 02/20/26, and the 02/01/26 through 03/11/26 MAR were reviewed, and the following was identified: a. Senna 8.6 mg tablet, give one tablet twice daily, was not administered on 16 occasions between 02/01/26 and 03/11/26 because the medication was not available. During an interview on 03/13/26 at 4:30 pm with Staff 1 (ED), he confirmed the medication was a “house stock” for the facility and the medications were not ordered timely. b. On 02/07/26, Resident 1 had the following new orders: * Take nutrition supplement Ensure twice a day between meals for weight loss. The MAR revealed the nutritional supplement was scheduled at 8:00 am and 5:00 pm, during facility mealtimes, not between meals as ordered. On 03/13/26 at 9:53 am, Staff 6 (MT) confirmed the Ensure was given with breakfast. * Arrange for a dietician consultation for weight loss. On 03/13/26 at 4:30 pm, Staff 1 (ED) confirmed the dietician consultation was not arranged. The need to ensure medication and treatment orders were carried out as prescribed was discussed with Staff 1 on 03/13/26 at 4:30 pm. He acknowledged the findings. 2. Resident 2 moved into the MCC in 03/2022 with diagnoses including Alzheimer’s disease. The resident's 02/01/26 to 03/11/26 MARs and physician orders, dated 02/19/26, were reviewed, and the following was identified: a. The following medications were ordered by the physician: * Bisacodyl 10 mg suppository QD PRN (for constipation); * Glycopyrrolate 1 mg tablet every four hours PRN (for secretions); * Lorazepam 0.5 mg tablet every two hours PRN (for anxiety/shortness of breath); and * Morphine 0.25 mL every four hours PRN (for pain). There was no indication the above orders were transcribed to the resident’s 02/19/26 through 03/11/26 MAR. b. Resident 2’s 02/19/26 – 03/11/26 MAR showed Milk of Magnesia give 30mL once a day as needed for constipation. There was no documented evidence the facility had a signed physician or other legally recognized practitioner order to administer the medication. In an interview on 03/12/26 at 11:35 am, Staff 4 (RCC) acknowledged the above orders were missing from Resident 2’s MAR and there was no order for Milk of Magnesia. The need to ensure all written, signed orders from a legally recognized practitioner were carried out as prescribed was discussed with Staff 1 (ED) on 03/13/26 at 3:55pm. He acknowledged the findings.

1- The residents (#1 & #2) identified in the survey have had their PCP orders reviewed to ensure accuracy of the orders. Additionally, the nutritional supplement timeframes have been adjusted to reflect more appropriate administration timeframes. RN has completed an assessment for weight loss and has determined that the current interventions have been effective for the resident and will reach out if a dietician consultation needs to be completed. Resident #2 has had the PCP orders reviewed for accurate transcriptions to the MAR. 2- All Resident physician orders have been reviewed for accuracy. And updated orders have been sent out to PCP for review and clarification as needed. The RCC and RN will review the MAR and clinical dashboard daily to identify any medications not administered, unavailable medication or transcription discrepancies. If a medication is found to be out of stock, the medication will be reordered immediately, the pharmacy will be contacted the same day, and the physician will be notified as appropriate for any missed or delayed doses. Routine audits of the med cart, MAR & PCP orders will be conducted to ensure medications are available and the physician orders are accurately transcribed and followed as written. Any discrepancies will be corrected immediately and reviewed through the Quality Assurance program. 3- All physician orders will be reviewed, printed and sent out to the PCP's on a routine 90 day schedule. On return of these signed orders, the orders will be reconcilied for accuracy. This system will be reviewed every 90 days and as needed with changes to the residents orders. 4- The RCC and RN will be responsible for compliance.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order.

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 observation, interview, and record review, it was determined the facility failed to ensure a sufficient number of direct care staff were present at all times to meet the 24-hour scheduled and unscheduled needs of each resident, failed to increase staffing to maintain resident care and services with the use of universal workers and failed to ensure fire safety evacuation standards were met. Findings include, but are not limited to: On 03/11/26 the “ABST [acuity-based staffing tool] Facility Entrance Questionnaire” was provided to the facility and was returned on 03/12/26. The following was noted: * The memory care was home to 23 residents; * The facility had two shifts: Day shift was 6:00 am to 6:00 pm, and the overnight shift was 6:00 pm to 6:00 am; * Five residents required support with dining services; * Three residents required two-person transfers; and * Four residents required assistance with behavioral support. a. On 03/12/26 at 9:34 am, Staff 1 (ED) reported the facility had one housekeeper who also provided direct-care and regularly worked as a caregiver. Staff 1 stated the caregiving job responsibilities included assisting residents with housekeeping, laundry, and dining services in addition to providing direct resident services. The caregiving responsibilities provided by Staff 1, define the role of a universal worker, which was reviewed with Staff 1. Staff 1 confirmed the caregivers met the definition of a universal worker and staffing was not increased to maintain resident care and services with the use of universal workers. b. On 03/13/26 at 10:32 am, Staff 1 reported there wasn’t a current system to ensure time for resident’s unscheduled needs were accounted for on the ABST. c. On 03/12/26 at 12:42 pm, Staff 1 reported fire drills had not been conducted on the overnight shift in the past six months and confirmed he needed to review the overnight staffing plan. The need to ensure a sufficient number of direct care staff were present at all times to meet the 24-hour scheduled and unscheduled needs of each resident, staffing was increased to maintain resident care and services with the use of universal workers, and ensure fire safety evacuation standards were met, was reviewed with Staff 1 on 03/13/26 at 3:19 pm. He acknowledged the findings.

1- The ABST tool has been reviewed and updated to reflect the current resident acuity, including care needs, dining assistance, behavior management, and evaluation requirements. Staffing adjustments have been made to staff up for the use of universal workers, account for unscheduled resident needs, and ensure sufficient overnigt staffing to safely evacuate dependent residents in the event of an emergency. 2- The ABST tool will be updated prior to admission, upon admission, with any change in resident condition, and at least quarterly to reflect both scheduled and unscheduled needs of residents. Daily stand up meetings will include review of residents acuity, unscheduled needs and staffing adjustments. Staffiing levels will be modified based on ABST findings to ensure compliance with fire safety evacuation standards, including overnight staffing requirements. 3- The ABST tool will be reviewed daily in the Stand Up / Clinical meetings to ensure that all care needs have been captured and that the tool itself is accurate. Staffing will be adjusted timely per the tool. This system will be monitored and audited for accuracy minimally 3 times weekly. 4- The ED will ultimately be responsible for compliance.

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 acuity-based staffing tool (ABST) was reviewed and updated when a resident experienced a significant change of condition, for 1 of 2 sampled residents (#2) and failed to use the results of the ABST to develop and routinely update the facility’s posted staffing plan. Findings include, but are not limited to: The facility’s ABST data and documentation provided with the Department’s “ABST Entrance Questionnaire” was reviewed, and the following was identified: a. Resident 2 experienced a significant change of condition on 12/15/25, and the resident’s individual ABST evaluation noted it was last reviewed and updated on 11/15/25, indicating the resident’s ABST evaluation was not reviewed and updated associated with the significant change of condition. b. On 03/13/26 at 9:34 am, Staff 1 (ED) reported the last update to the posted staffing plan was approximately one year ago and confirmed it was not reflective of the current staffing level. The need to ensure residents’ ABST evaluations were reviewed and updated associated with significant changes of condition and the results of the ABST were used to develop and routinely update the facility’s posted staffing plan was reviewed with Staff 1 on 03/13/26 at 3:19 pm. He acknowledged the findings.

1- The ABST tool has been reviewed to reflect the accurate number of staff needed based on residents care needs, dining assistance and behavior management. To include residents identified on the survey (#1 & #2) Adjustments have been made to reflect these needs as well as the abilty for staff to safely evacuate the dependent resident in the event of an emergency. And this updated and the staffing plan is posted. 2- When the RN identifies a significant change of condition, the ABST will be updated immediately to reflect the residents revised care needs. The community's posted staffing plan will be updated from the revised ABST data the same day to ensure it accurately reflects current resident acuity and staffing requirements. The posted staffing plan will be updated daily and with any changes to resident condiiton or census to ensure ongoing compliance. 3- The ABST tool will be reviewed daily in the Stand Up / Clinical meetings to ensure that all care needs have been captured and that the tool itself is accurate. Staffing will be adjusted timely per the tool. This system will be monitored and audited for accuracy minimally 3 times weekly. Postings will be updated daily and with changes. 4- The ED will ultimately be responsible for compliance.

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, the facility failed to ensure unannounced fire drills were conducted on different shifts. Findings include, but are not limited to: On 03/12/26, fire drill and fire and life safety records for the previous six months were requested and reviewed with Staff 1 (ED). The following was identified: a. There was no documented evidence the facility conducted fire drills on the overnight shift. b. Staff 1 scheduled all fire drills at the same time every month. The need to conduct unannounced fire drills on all shifts was reviewed with Staff 1, on 03/13/26 at 3:19 pm. He acknowledged the findings, and no additional documentation was provided.

1. The Maintenance Manager will have required unannounced fire and life safety drills monthly from day and night shift. 2. The Maintenance Manager will conduct unannounced fire drills rotating from day to night monthly. 3. The system will be evaluated once a month during monthly management meetings. 4. The Executive Director will be responsible for compliance.

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 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair.

Based on observation and interview, the facility failed to keep all interior materials and surfaces clean and in good repair and to keep the interior free from unpleasant odors. Findings include but are not limited to: From 03/11/26 through 03/13/26, the interior of the facility was toured and the following was identified: a. The following areas were noted to be unclean and/or in need of repair: * Walls, baseboards, and wall corners had scratches, paint chips, and/or gouges in multiple areas throughout the facility; * The following doors and/or door frames were scratched, chipped, and/or gouged: Resident room #s 1, 2, 3, 6, 10, and 14, “Shower Room 2,” and the Medication Room; * The flooring was chipped, scratched, and peeling in the dining room, television/living room, and in the corridor intersection near room 13 and the television/living room, and there was an approximate one by one inch hole outside the “Fire Riser Room”; * Three dining chair seat cushions had scuffed and peeling seats, making them uncleanable; * The television/living room had what appeared to be an air conditioning unit mounted at the top of a wall which was noted to have dark spot and appeared unclean; and * The flooring throughout the facility had multiple areas with dark spots, dirt/dust, food wrappers, and food debris and were sticky. b. Throughout the survey, a pervasive, unpleasant odor was noted throughout the facility. On 03/13/26 at 11:36 am, a walk-through was completed with Staff 1 (ED) and at 12:04 pm, Staff 1 stated he agreed with the areas identified above. The need to ensure all interior materials and surfaces were clean and in good repair and the interior was kept free from unpleasant odors was reviewed with Staff 1 on 03/13/26 at 3:19 pm. He acknowledged the findings.

1. Maintenance Manager will repair identified areas including walls, wall corners and baseboard and flooring in the DR, tv/living room, corridor by 13 and Fire riser room. The dining chairs that are uncleanable will be replaced or repaired 2. Maintenance will conduct a monthly walkthrough with the Executive Director to ensure the community remains in good condition, and a dedicated housekeeper will be hired. 3. Monthly by Maintenance and Executive Director during cheduled environmental rounds to ensure community remains in good condiiton and compliant with regulations. 4. The Executive Director will be responsible for compliance.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair.

OAR 411-054-0070 (3)(b)(A)(B)(C) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule.

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation, including the Department-approved LGBTQIA2S+ course, was completed prior to beginning job responsibilities for 2 of 4 newly hired staff (#s 7 and 11) whose training records were reviewed. Findings include, but are not limited to: Refer to Z155.

1- The staff that have been identified in the survey have been given clear instructions and guideance that the training modules are completed. 2- All employee files have been auditied to ensure that all required training is completed per rules. All new hires will be audited for completion of the required trainings and current staff will be promted with required on going required trainings. This is include all pre-servcie orientation, Department approved LGBTQIA2S+ course. 3-All employee files will be audited on hire, upon completion of all of the required training for compliance, or they will not be allowed access to the residents unitl completed. Routine auditing will be completed monthly for compliance. The Business Office Manager and the ED are responsible for over all compliance.

OAR 411-054-0070 (3)(b)(A)(B)(C) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule.

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, and C513

Refer to C231, C295, C360, C363, C420, and C513

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 4 of 4 newly hired staff (#s 7, 8, 11, and 12) completed all pre-service orientation training prior to beginning their job responsibilities and completed all required pre-service dementia trainings prior to independently providing personal care or other services to residents. Findings include, but are not limited to: Staff training records were reviewed on 03/12/26 at 10:52 am, with Staff 3 (Business Office Manager), and the following was identified: a. There was no documented evidence Staff 7 (MT), hired 07/10/25, Staff 8 (MT), hired 08/29/25, Staff 11 (CG), hired 10/22/25, and Staff 12 (Housekeeper/CG), hired 10/02/25, completed required pre-service orientation training prior to beginning job duties in one or more of the following areas: * Abuse reporting requirements; * Fire and safety and emergency procedures; * Infectious disease prevention; * Approved HCBS course; and * Approved LGBTQIA2S+ course. b. There was no documented evidence Staff 7, Staff 8, Staff 11, and Staff 12 completed one or more of the following pre-service dementia training topics prior to independently providing personal care or other services to residents: * Environmental factors that are important to a resident's well-being (e.g., staff interactions, lighting, room temperature, noise, etc.); * Family support and the role the family may have in the care of the resident; * How to recognize behaviors that indicate a change in the resident’s condition and report behaviors that require on-going assessment; * How to provide personal care to a resident with dementia, including an orientation to the resident's service plan; and * Use of supportive devices with restraining qualities in memory care communities. The need for staff to complete all required pre-service orientation training and for direct care staff to complete required pre-service dementia training was reviewed with Staff 1 (ED) on 03/13/26 at 3:19 pm. He acknowledged the findings, and no additional documentation was provided.

1- All employee files have been audited for compliance for the required training in this Z155 area of regulations. (OAR 411-054-0070(3). All training, has been completed. 2- All employee files will be reviewed on hire, 30 day, on going required training of 16 hours of in-servicing annually, 6 hours of annual Dementia training, to include the Pre-service dementia training, and other trainings as outlined in the rule. Staff competencies will be completed annually to ensure that trainings are documented by the community. 3- The Business Office Manager will be auditing all employee files to ensure compliance on a weekly basis for compliance. 4- The business Office Manager and ED will be responsible for compliance.

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 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. Findings include, but are not limited to: Refer to C260, C270, C280, C290, and C303.

*** Refer to C260, C270, C280, C290, and C303.

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 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991

Based on interview and record review, it was determined the facility failed to ensure resident evaluations addressed all required elements for 1 of 1 sampled resident (# 1) whose move-in evaluation was reviewed. Findings include, but are not limited to: Resident 1 moved into the facility in 05/2025 with diagnoses including dementia, depression, and chronic pain. The resident's move-in evaluation was reviewed and lacked the following required elements: * List of current diagnoses; * List of medications and PRN use; * Mental health issues, including history of treatment and effective non-drug interventions; * Personality, including how the person copes with change or challenging situations; * Ability to use the call system; * Non-drug interventions for pain; * History of dehydration; * Recent losses; * Smoking, ability to smoke safely; * Alcohol and drug use; * Environmental factors that impact the resident's behavior including, but not limited to, noise, lighting, room temperature; * Preferred pronouns; and * Gender identity. The need to ensure all required elements were addressed on the resident's move-in evaluation was discussed with Staff 1 (ED) and Staff 2 (RCC) on 08/14/25 at 2:40 pm. They acknowledged the findings.

All Move-in Evaluations will be updated to address all missing elements. The systems (EHR) to ensure the completion of move-in evaluation will be evaluated by WD, RCC and ED to confirm that all move-in evaluations elements are complete prior to approving future resident’s move-in date. Monthly and/or whenever there’s new move-in. The RCC &/or Executive Director will be responsible for overseeing that the above systems are in place and continuously monitored

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991

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 interview and record review, it was determined the facility failed to ensure service plans were reflective of the residents’ needs and included a written description of who should provide the services and what, when how, and how often the services should be provided for 3 of 4 sampled residents (#s 1, 2, and 3) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 05/2025 with diagnoses including dementia, type 2 diabetes mellitus, depression, and chronic pain. The resident's service plan, dated 06/25/25, and MARs, dated 07/01/25 through 08/12/25, were reviewed, and staff were interviewed. The service plan lacked clear direction to staff which included a written description of who should provide the services and what, when, how, and how often the services should be provided in the following areas: * What triggered Resident 1's anxiety and effective non-drug interventions; * How the resident exhibited episodes of being hyperglycemic and hypoglycemic; * How staff should assist and reassure Resident 1 with forgetfulness and difficulty concentrating; * How to prompt the resident in order to help with forgetfulness, difficulty understanding, and communicating needs; * Staff assistance with leisure activities and where the supplies were located; and * Non-drug interventions for pain relief. The need to ensure the service plan provided clear caregiving instruction to staff which included a written description of who should provide the services and what, when, how, and how often the services should be provided was discussed with Staff 1 (ED) and Staff 2 (RCC) on 08/14/25 at 2:40 pm. They acknowledged the findings. 2. Resident 2 moved into the facility in 04/2025 with diagnoses including dementia and basal cell carcinoma. The resident's service plan, dated 07/23/25, Change in Service Plan, dated 04/11/25, and progress notes, dated from 04/11/25 through 08/06/25, were reviewed, and staff were interviewed. The service plan lacked clear direction to staff which included a written description of who should provide the services and what, when, how, and how often the services should be provided in the following areas: * Facial hair and how staff were to assist the resident; * What needs the resident had that staff should attempt to anticipate; * Where staff could locate non-alcoholic beer and root beer relating to behavior interventions; * Interventions for staff to use when Resident 2 became angry with them; * Direction on how to redirect and reassure the resident if s/he became confused, disruptive, aggressive, or socially inappropriate; * How Resident 2 showed anxiety and non-drug interventions staff could utilize for the behavior; and * The potential for skin lesions and to whom they should be reported. The need to ensure the service plan provided clear caregiving instruction to staff which include a written description of who should provide the services and what, when, how, and how often the services should be provided was discussed with Staff 1 (ED) and Staff 2 (RCC) on 08/14/25 at 2:40 pm. They acknowledged the findings. 3. Resident 3 moved into the facility in 10/2024 with diagnoses including dementia. The resident's service plan, dated 07/23/25, and progress notes, dated 03/28/25 through 08/01/25, were reviewed, and staff were interviewed. The service plan lacked clear direction to staff which included a written description of who should provide the services and what, when, how, and how often the services should be provided in the following areas: * The use of compression stockings; * How Resident 3 helped with dressing and toileting; * Interventions for staff to use to manage and reduce sundowning; * How staff were to provide extensive intervention to support the resident's dementia related conditions; * How staff could help Resident 3 when s/he felt disoriented; * Interventions for redirection out of other residents' rooms; and * Non-drug interventions related to resisting care, verbal behaviors, hallucinations, and delusions. The need to ensure the service plan provided clear caregiving instruction to staff which include a written description of who should provide the services and what, when, how, and how often the services should be provided was discussed with Staff 1 (ED) and Staff 2 (RCC) on 08/14/25 at 2:40 pm. They acknowledged the findings.

All service plans will be reviewed and audited to reflect residents’ current care are reflective and provide clear instructions to the staff. To prevent recurrence, all service plans will be audited by RCC in August Health so that all elements will be included and reflective to residents’ service plan. Upon move-in of resident, 30-days after move-in, every 90 days and whenever there’s change of condition. The RCC and/or Executive Director will be responsible for overseeing that the above systems are in place and continuously monitored.

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 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility.

Based on interview and record review, it was determined the facility failed to ensure medications that were given to treat a resident's behavior had resident-specific parameters and non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of psychotropic medications for 1 of 1 sampled resident (# 3) who was prescribed and administered a PRN psychotropic medication. Findings include, but are not limited to: Resident 3 moved into the facility in 10/2024 with diagnoses including dementia. The resident's MARs, dated 07/01/25 through 08/12/25, and progress notes, dated 03/28/25 through 08/01/25, were reviewed and staff were interviewed. The following was noted: Resident 3 had a physician's order for quetiapine (to treat agitation and aggressive behavior), 25 mgs, PRN. The resident received the PRN medication on: * 07/02/25; * 07/08/25; * 07/10/25; * 07/15/25; and * 08/07/25. There was no documented evidence that non-pharmacological interventions were tried and failed prior to the administration of the PRN psychotropic. On 08/14/25 at 2:25 pm, Staff 5 (MT) reviewed the electronic medication program with the surveyor and confirmed there were no non-pharmacological interventions listed for staff to try prior to administering the PRN, nor was there a place to document when non-pharmacological interventions were tried and failed prior to the administration. The need to ensure medications given to treat a resident's behavior had resident-specific parameters and non-pharmacological interventions were attempted and documented as ineffective prior to the administration of psychotropic medications was discussed with Staff 1 (ED) and Staff 2 (RCC) on 08/14/25 at 2:40 pm. They acknowledged the findings.

Wellness Director/RN will complete a comprehensive MAR review for all residents with PRN psychoactive medications and will add resident specific non-pharmacological interventions. All orders for PRN psychoactive medication will be reviewed prior to administering medications, and resident specific non-pharmacological interventions will be added thru Quickmar-note. Monthly and whenever there’s new PRN psychoactive medication order. The Executive Director and/or Wellness Director/ RN will be responsible for ensuring the corrections are completed and monitored.

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility.

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 acuity-based staffing tool (ABST) was completed before a resident moved in to the community and/or no less than quarterly at the same time the resident’s service plan was updated for 3 of 4 sampled residents (#s 1, 2, and 3) and multiple unsampled residents whose ABST updates were reviewed. In addition, the facility failed to use the results of the ABST to develop and routinely update the facility’s posted staffing plan. Findings include, but are not limited to: On 08/12/25 the facility provided the ABST Entrance Questionnaire and the corresponding documentation that was requested. The following was identified: 1. The residents’ ABST updates were reviewed on 08/12/25 and the following was noted: a. Resident 1, Resident 2, and four unsampled residents’ data was not entered into the ABST prior to move-in. b. Resident 3 and 14 unsampled residents’ ABST information had not been updated quarterly at the same time their service plans were updated. 2. The facility had two, 12-hour shifts. The following was noted: a. The posted staffing plan reflected: * Day Shift: One MT and two CGs; * Night Shift: One MT and one CG; and * 9:00 am to 9:00 pm: An additional CG. b. The ABST reflected five out of seven days, from 6:00 am to 6:00 pm, were not staffed per the tool’s calculated resident minutes. The need to ensure residents’ data in the ABST was entered prior to move-in and updated quarterly when the service plan was updated, and the need for the facility to use the results of the ABST to develop, and routinely update, the facility’s posted staffing plan was discussed with Staff 1 (ED) and Staff 2 (RCC) on 08/14/25 at 2:40 pm. They acknowledged findings.

ABST will be reviewed and completed before resident move-in and will be updated accordingly whenever there’s change in service plan. . RCC will ensure the acuity-based staffing tool (ABST) will be completed before resident moves into the community and/ or as changes/ updates occur in the service plan or have a change of condition. RCC will make sure that the posted staffing plan reflects the changes in ABST. Monthly and whenever there’s service plan changes. The RCC and/or Executive Director will be responsible for the ABST is updated and completed.

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 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair.

Based on observation and interview, the facility failed to keep all interior materials and surfaces clean and in good repair. Findings include but are not limited to: The interior of the facility was toured on 08/12/25 at 11:30 am. The following were identified: * Walls, baseboards, and corner walls had paint chips and gouges in multiple areas throughout the facility; * Five dining chair seat cushions had scuffed and peeling seats making them uncleanable; * Floor planks in front of Room 15 had separated and raised; * The television room floor showed a four-inch by four-inch hole in one plank with multiple damaged areas; and * The television room hall showed a four-foot long area of separated planks. The areas in need of repair were reviewed with Staff 1 (ED) during an environment walk through on 08/13/25 at 2:00 pm. He acknowledged the findings.

The facility will ensure to keep all interior materials and surfaces clean and in good repair. Walls, baseboards and corner walls will be re-painted and maintained clean throughout the facility. The five dining chairs seat cushions will be upholstered and/or replaced. The floor planks in front of Room 15 will be repaired. The television room floor will be replaced by vendor that will be contracted by the facility. Maintenance Director will ensure that the interior materials and surfaces throughout the facility are maintained, clean and in good standing. Maintenance Director will keep a monthly task log to indicate completion and prioritizing repairs. Monthly. The Maintenance Director and/or Executive Director will be responsible that all repairs and replacement completed, and facility is well maintained.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair.

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit.

Based on observation and interview, it was determined the facility failed to ensure individual privacy for residents who shared a bathroom. Findings include but are not limited to: During environmental observations on 08/12/25, multiple shared units were observed to have a shared bathroom without the ability to lock the door. In a tour with Staff 1 (ED) on 08/13/25 at 11:00 am, it was confirmed the shared units did not have a lockable bathroom door. The need to ensure residents were provided with individual privacy in his or her own unit was discussed with Staff 1 and Staff 2 (RCC) on 08/14/25 at 2:30 pm. They acknowledged the findings.

The facility will ensure individual privacy for residents who shared a bathroom will have ability to lock the door. All shared rooms will have an installed lock in their shared bathroom door. Maintenance Director will install the lock on shared bathroom doors in each shared room. Monthly and as needed whenever there’s new move-in to unit that has shared bathroom. The Maintenance Director and/or Executive Director will be responsible for making sure that all shared bathroom doors have lock installed and maintained.

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit.

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit.

Based on observation and interview, it was determined the facility failed to ensure residents had a key to their unit. Findings include, but are not limited to: On 08/12/25, an observation showed an unsampled resident attempt to enter his/her room and was unable to enter due to the door being locked. During an interview with Witness 1 (Family Member/POA) on 08/14/25, it was reported their family member did not receive a key at move-in. In an interview on 08/14/25, Staff 1 (ED) confirmed keys were not provided to residents. The need to ensure the individual and only appropriate staff had a key to access their unit was reviewed with Staff 1 on 08/14/25 at 2:00 pm. He acknowledged the findings.

The facility will ensure all residents and/or families have a key to their individual unit. Maintenance Director will ensure keys are available prior to move-in to be given to residents and/or family. Documentation of issuance of keys will be entered to their chart notes. Every time there will be new move-in. The Maintenance Director and/or Executive Director will be responsible for making sure that all new residents and/or family will be provided with a key to their unit.

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit.

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (c) Each resident record must, before move-in and when updated, include the following information: (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name (B) Pronouns. (C) Gender identity.

Based on interview and record review, the facility failed to ensure move-in evaluations addressed all required elements, including pronouns and gender identity, for 1 of 1 sampled resident (# 1) whose move-in evaluations were reviewed. Findings include, but are not limited to: Refer to: C 252.

Please refer to C252

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (c) Each resident record must, before move-in and when updated, include the following information: (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name (B) Pronouns. (C) Gender identity.

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 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: C 513.

Please refer to C513.

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 411-057-0160(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 252, C 260, C 330, and C 363.

Please refer to C252, C260, C330 and C363.

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 for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose records were reviewed. Findings include, but are not limited to: Resident 1, 2, 3, and 4’s records were reviewed during the survey. There was no resident-specific activity plan which detailed what, when, how, and how often staff should offer and assist the residents with individualized activities. Individualized activity plans were not included on the resident's activity plan or service plan. The need to ensure residents’ individualized activity plans were developed was discussed with Staff 1 (ED) on 08/14/25 at 11:00 am. He acknowledged the findings.

The facility will ensure individualized activity plans were developed and updated based on the activity evaluation for the residents. Resident-specific activity plan which detailed what, when, how and how often staff should offer and assist the residents with individualized activities which will be included in their service plan. To prevent recurrence, all activity plans will be audited by Activity Director and/or RCC to reflect on the residents’ current activities and provide clear directions to the staff. Upon move-in, 30-days after move-in, every 90-days and/or whenever there’s change in service plan that could affect residents’ activities. The RCC, Activity Director and/or Executive Director and the Activity Director will be responsible for overseeing the fact that the above systems are in place and continuously monitored.

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 kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 09/07/23 at 11:10 am, the facility kitchen was observed and the following was noted: * The refrigerator interior walls had food splatter/spills; * Food items were uncovered in refrigerator (sliced oranges) and in the freezer (individual desserts); * An open bag of dinner rolls in the freezer; * Scoops were in food product sacks (stored in bins), items included, granulated sugar, powdered sugar and oatmeal; * One garbage can was uncovered when not in use; * The hood vents above stove/grill were greasy/dusty, per Staff 1 (Cook/PIC) the hood was commercially cleaned with last cleaning on 04/17/23, next scheduled service in 26 weeks; * One staff was not using any type of hair restraint; and * Several non-kitchen staff entered the kitchen throughout the inspection. The areas of concern were observed and discussed with Staff 1 on 09/07/23. The findings were acknowledged.

C240 Resident Services Meals. Food Sanitation Rule 1a) Daily inspection of the kitchen, dining room, flooring and refrigerator will be conducted by the Administrator and Chef to make sure Kitchen is clean daily. b) Daily inspection of Kitchen Freezer, Kitchen Refrigerator by Administrator and Chef to make sure the proper storing of food items, and making sure all open food items are stored in food containers, bins and are date and labeled. Completed on 9/12/2023. c) Daily inspection of the Dry Storage area by Administrator and Chef to make sure that no scoops are inside food product sacks (stored in bins) Removed and educate Chef on 9/12/2023. d) Weekly inspection of the Hood Vents by Administrator and Chef to make sure the Hood Vents looks clean.  Will notify Hot Shot Hood Cleaning is observe Hood vents needs cleaning. Schedule Hood Cleaning is set for 9/29/2023. e) Administrator prepares the menus 30 days in advance, menus are available to the family members, visitors and staff and posted on the bulleting board in the dining room. Administrator go over the menu in advance with Chefs and educate Chef's if product is not available according to the menu posted for the week, Chefs are to notify Administrator, Staff and resident of the menu change. f) Three meals per day is available daily 7 days per week.  Snacks are available three times daily 7 days per week.  Alternatives are available daily 7 days per week if a resident refuses food being served. Weekly delivery of fresh fruit and vegetables every Thursday with US food order. g) Modify special diets are accommodate daily 7 days per week in accordance with diet orders from PCP.  Administrator follow up daily with Chefs to make sure proper nutrition is being offered daily. h) Administrator and Chef is to make sure food is prepared and serve three times daily, 7 days per week. i) Administrator and Chef is to make sure that the Garbage Can is closed at all times--Copleted on 9/12/2023. j) Administrator ordered a box of hairnets for the dining services team.  Order was placed on 9/12/2023.  Educate the dining services team to wear hairnets while in the kitchen. k) Administrator educate the whole team on 9/12/2023 that Kitchen staff are to be in the kithcen, non kitchen staff are to ask the Kitchen staff for items needed from the ktichen.  A all staff meeting in schedule for 9/25/2023 to go rules and expectations. Daily communication with the Chefs to assure things are working and functioning well. Administrator

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 C 240.

Z142 1) Administrator will conduct daily walkthough of the Kitchen area to make sure the whole kitchen is clean, organized, food labeled, no open food observe. Daily communication with the Chefs to make sure policy and procedures are followed daily. 2) Administrator will communicate daily to the Chefs and staff to report any damages or things out of place so that Administrator can follow up, document and communicate to the owner. 3) Administrator will conduct daily walk through. Report the fininds to owner on a weekly basis. 4). Administrator.

The findings of the kitchen inspection, conducted 09/07/23, 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 09/07/23, conducted 10/30/23, are documented in this report. It was determined the facility was in substantial 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.

Based on observation, interview, and record review, conducted during a site visit on 06/27/23, it was confirmed the facility failed to fully implement an Acuity Based Staffing Tool (ABST). Findings include, but are not limited to: In an interview on 06/27/23, Staff 1 (Administrator) and Staff 2 (RCM) stated the facility had not adopted an ABST. Staff stated there are to be three caregivers (CG) and one medication aide (MA) on day and swing shift, and two CGs and one MA on night shift. On 06/27/23, it was observed the facility was staffed with three CGs and one MA on day shift. There was no documented evidence the facility was using an ABST that would determine a staffing plan reflective to meet the 24-hour scheduled and unscheduled needs of residents. On 06/27/23, these findings were reviewed with and acknolwedged by Staff 1 and Staff 2. Staff 1 stated the owner had a log-in but never sent it to the facility. The facility failed to adopt and fully implement an Acuity Based Staffing Tool (ABST). Verbal Plan of Correction: Effective immediately, the Administrator will enter all resident acuity information into the ODHS ABST and estimates it will be completed by end of day 06/28/23.

The findings of the on-site investigation, conducted 06/27/23 are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. 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 RCM: Resident Care Manager RN: Registered Nurse

Based on observation and interview, it was determined the facility failed to prepare and serve food in accordance with the Food Sanitation Rules OAR 333-150-00. Findings include, but are not limited to: A tour of the kitchen on 05/23/22 and the dining room on 5/25/22 showed the following areas in need of cleaning or repair: A. Main Kitchen * Scratches and chips in the tile flooring, creating an uncleanable surface; and * Broken lower shelving on each of three metal carts, including one supported by cans of food and one supported by a cardboard box. B. Dining Room * Worn varnish on beverage and snack cabinet countertop, exposing bare wood and creating an uncleanable surface; and * Buckling and separating vinyl flooring, including a separated area approximately 24" x ½", exposing underflooring. C.  Refrigerator/freezer in the upstairs kitchen * Drips of dark purple sticky substance on walls of freezer and frozen to the outside of food packages. Findings were discussed with Staff 1 (Administrator) on 05/24/22 and 05/25/22. She acknowledged the findings.

Z142/C240 Resident Services Meals, Food Sanitation Rule 1) Daily inspection of the kitchen, dining room, flooring and refrigerator (upstairs) will be conducted by the Administrator and Chef.  Administrator will submit the finding to the owner for a plan to repair. * Broken lower shelving on three metal carts were fixed on 5/26/2022. * Worn varnis on beverage and snack countertop fixed 6/20/22. * Refrigerator (upstairs) cleaned as of 5/27/2022 (no food items stored) 2} Daily communication with the Chef to assure things are working and functioning well. 3} Administrator will submit weekly reports to the owner of the Kitchen, dining room, and flooring of the daily inspections of areas needed to be repair. 4} Administrator

2. Resident 1 was admitted to the facility in 03/2021 with diagnoses including dementia. a. Observations of the resident, interviews with staff, service plan dated 03/08/22 and Temporary Service Plans (TSPs) were reviewed. The service plan was not reflective of the resident's current status or lacked caregiving instructions in the following areas: * Toileting assistance; * Frequency of incontinent checks; * Two person transfer assistance at times; * The ability to manage ambulation and mobility independently; * Mobility device currently used; * Dining; * Behavioral issues and interventions; * Duties of private caregivers; * Activities; and * Fall interventions. b. On 05/13/22, a TSP was initiated noting Resident 1 had a new roommate. The TSP was not resident specific as it directed staff to "take all vital signs" and "push fluids." The need to ensure service plans were reflective of the resident's status and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 05/25/22. 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' current care needs, updated with changes, and provided clear direction to staff regarding the delivery of services for 2 of 3 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 06/2019 with diagnoses including dementia with behavioral disturbance and history of stroke. Observations of the resident, interviews with staff, and review of the service plan dated 05/19/22, indicated the service plan failed to reflect the resident's current care needs relating to oral care. The need to ensure service plans were reflective of the resident's status and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 05/25/22. They acknowledged the findings.

Z162/C260 -Service Plan 1} Health Service Director will complete a initial evaluation, 30 day and quaterly as well as Significant Change of Condition for any resident.  The Initial evaluation tool has been updated to reflect some changes in collecting accurate information about a resident to build a personalized Service Plan for the resident so that family understand the care needs provided. Staff will be educated about each Service Plan implemented to understand and follow.Health Service Director to communicate any updates or changes to the Service Plan to family and staff. 2} Service Plan will have a three check system so that any inconsistencies will be noted and fixed. 3} Service Plans are to be reviewed after 30 days and quaterly and at Change of Condition. Monthly audits will be conducted. 4} Service Plans will be written and reviews by Health Service Director, RN and Administrator.

Based on observation, interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed for changes of condition including resident specific instructions communicated to staff on each shift, updated the service plan and monitored the resident consistent with the  evaluated needs for 1 of 2 sampled residents (# 1) who experienced changes of condition. Resident 1 had repeated falls with injury. Findings include, but are not limited to: Resident 1 was admitted to the MCC in 03/2021 with diagnoses including history of falls and dementia. During the acuity interview, Resident 1 was identified as a fall risk and at times required two people for ADL assistance. The 10/27/21 service plan was reviewed and the following fall interventions were documented: * Room should be free of clutter, no cords should be out and lighting should be sufficient for ambulating; * Provide safety checks when in room especially at night; * Encourage the resident to stay in common area for better visual monitoring; * Use wheelchair for long distance transport; * Always turn pressure alarm on. Notify MT or nurse if alarm is not functioning well or low on battery; * Remind the resident to look behind him/her first before sitting; * Remind to always use front wheel walker for short distance ambulation; * Use one person assist for transfers; * Provide and remind to use call system at all times; * Ensure s/he is wearing proper footwear for all mobility; and * Leave bathroom lights on at night. The resident record was reviewed and noted nine falls between 10/25/21 and 05/21/22. The service plan was updated on 12/16/21 and 3/8/22. The fall interventions remained the same and noted the addition of a private caregiver from 2:00 pm - 6:00 pm daily. Temporary service plans dated 10/25/21 through 5/21/22 noted continued safety checks every one to two hours while the resident was in bed/apartment and chart interventions to prevent falls from reoccurring. Observations of Resident 1 throughout the survey showed light green bruising across his/her face, over the bridge of the nose and below the eyes. The resident's upper lip was swollen on the left side. On 05/25/22 at 1:09 pm, Staff 10 (CG) stated fall interventions included not laying the resident down in his/her room, the resident was kept in the common areas and had safety checks during the nights. Staff 10 stated the resident did not use a walker, did not have a pressure alarm but did have a "baby monitor." On 05/25/22 at 1:26 pm the resident's room was observed. The alarm component was located under the bed. The pressure pad component was observed between the fitted sheet and mattress, with the alarm cord disconnected. When the alarm was reconnected to the pressure pad, it was not functional when tested. There was also a "baby monitor" located to the left of the resident's television. On 05/25/22 at 1:32 pm, Staff 3 (RCC) confirmed the audio component of the "baby monitor" was located in the medication room. On 05/24/22 and 05/25/22, both Staff 1 (Administrator) and Staff 2 (Health Service Director) reported the resident often disconnects the alarm from the pressure pad. They were informed the pressure alarm was not in working order on 05/25/22. Resident 1 was identified to be at risk for falls and experienced multiple injury falls. There were multiple fall prevention interventions that were not reviewed with each fall to determine if they were in place and/or continued to be effective and the resident continued to fall. Resident 1's falls were reviewed with Staff 1 and Staff 2 on 05/25/22. No additional information was received.

Z162/C270--Change of Condition 1} Staff will document any noted changes to resident/s condition in QMAR under chart notes.  Health Service Director will monitor chart notes daily and implement temporary service plan change for short term change of condition or long term change of condition and initiate an assessment.  Health Service Director will monitor Change of Condition through resolution. 2} Staff will be trained and educated on reporting changes to baseline on a monthly inservice.  Health Serive Director will monitor Alert Charting and resident changes at least weekly and or through resolution. 3) Monthly audits will be conducted that will include monitoring Change of Condition and follow through 4} Health Services Director

2. Resident 1 was admitted to the facility in 03/2021 with diagnoses including dementia and depression. The 04/01/22 through 05/23/22 MARs, TARs and physician orders were reviewed and the following orders were not carried as prescribed: * Lexapro (for depression) not administered on 05/10/22 and 05/12/22 due to the medication not being available; * Daily bowel monitoring parameters were not followed; * PRN bowel medications were not administered per orders; and * Lidocain cream (for pain) was not administered on 12 occasions due to the medication not being available. 3. Resident 3 was admitted to the facility in 03/2022 with diagnoses including dementia. Resident 3's 05/01/22 through 05/23/22 MAR, TAR and physician's orders were reviewed. The physician's order reflected the following parameters for constipation: * Step 1 - Milk of Magnesia; * Step 2 - bisacodyl tablets; and * Step 3 - bisacodyl suppository. The parameters on the MAR directed staff to record bowel movements every shift, and to follow the bowel protocol if the resident had no bowel movement for two days. Per parameters, Resident 3 should have been administered Milk of Magnesia on the following dates and times: * Between 2:00 pm and 10:00 pm on 05/05/22; and * Between 2:00 pm and 10:00 pm on 05/10/22. Documentation on the MAR revealed bisacodyl tablets were administered on 05/05/22 at 12:26 pm and 05/10/22 at 12:16 pm. The need to ensure all medications and treatments were administered as prescribed by the physician was reviewed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 05/25/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 3 of 3 sampled residents (#s 1, 2 and 3) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 06/2019 with diagnoses that included dementia with behavioral disturbance and history of stroke. The 04/01/22 through 05/23/22 MARs, TARs and physician orders were reviewed and the following orders were not carried as prescribed: * PRN Milk of Magnesia (for constipation) nightly, for no bowel movement in 48 hours or more was not administered on 04/11/22, 04/15/22, 04/23/22 and 05/20/22 per parameters; * PRN bisacodyl suppository (for constipation) daily, if no bowel movement greater than three days, was administered on 04/12/22 after two days of no bowel movement; * Between 04/21/22 and 04/26/22 the resident went five days with no bowel movement and no PRN bowel medications; * Scheduled guaifenesin syrup (for cough), three times daily for seven days was administered for eight days plus one dose; and * Scheduled nystatin (for candidiasis fungal infection of the oropharynx) by mouth four times daily for 10 days with specific direction to swish in mouth for at least 30 seconds before swallowing, however, a progress note dated 05/21/22 by Staff 6 (MT) states "Swab [his/her] mouth with the new med, [the resident is] unable to swiss [sic] the new med." Staff 6 confirmed the resident was not administered the medication per physician's orders on 05/24/22 at 12:10 pm. The need to ensure all medications and treatments were administered as prescribed by the physician was reviewed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 05/25/22. They acknowledged the findings.

Z162/C303--Systems: Treatment Orders 1} Health Service Director will make sure Med Tech are following written orders as prescribe by Physicians.  Med Tech training will be held monthly to go over Physicians orders, Medication pass, medication parameters, bowel protocal medications, PRN and treatments.   2} Med Tech training was held on 6/10/2022 to go over the med tech role and Medication Management.  Understanding the importance of following orders and treatments.  Know the protocals, policy and procedures of making sure that medications and treatments are administed as order. 3} HSD will conduct a Monthly Audit and quaterly audits by our community Pharmacy (PharAmerica) 4} Health Service Director

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for all medications the facility was responsible to administer for 1 of 2 sampled residents (#4) whose orders were reviewed.  This is a repeat citation.  Findings include, but are not limited to: Resident 4 was admitted to the facility in 08/2022 with diagnoses including Lewy body dementia. Signed physician orders dated 08/26/22 noted the following medications were to be administered to Resident 4: *Hydralazine 25 mg tag three times daily (for hypertension); and *Sotalol 80 mg twice daily (for atrial fibrillation). The 08/26/22 through 08/31/22 MAR was reviewed and noted both medications had been discontinued on 08/25/22.  There was no documented evidence the resident received the medications as ordered from 08/26/22 through 08/31/22. During an interview on 08/31/22 at 4:10 pm, Staff 1 (Administrator) and Staff 12 (Health Services Director) acknowledged the medications were not being given as ordered.

C303--Systems: Treatment Orders 1} Health Service Director and Resident Care coordinator  will make sure Med Tech are following written orders as prescribe by Physicians.  Med Tech training will be held monthly to go over Physicians orders, Medication pass, medication parameters, bowel protocal medications, PRN and treatments.   2} Med Tech training was held on 9/8/2022 to go over the med tech role and Medication Management.  Understanding the importance of following orders and treatments.  Know the protocals, policy and procedures of making sure that medications and treatments are administed as order. 3} HSD and Resident care coordinator will conduct a Monthly Audit and quaterly audits by our community Pharmacy (PharAmerica) 4} Health Service Director and RCC

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included clear parameters for administration of prescribed medications for 2 of 3 sampled residents (#s 1 and 3) whose MARs and physician orders were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 03/2021 with diagnoses including dementia. The 04/01/22 through 05/23/22 MARs, TARs and physician orders were reviewed and showed the following inaccuracies: * On 05/09/22, staff documented they did not attempt three non-drug interventions prior to administering the PRN psychotropic, but when interviewed, they stated they did attempt the interventions; * Scheduled Lidocaine cream (for pain) had parameters to "apply topically to affected area 3 - 4 times daily," and * PRN albuterol (for shortness of breath or wheezing) to "inhale 1 - 4 puffs by mouth." 2. Resident 3 was admitted to the facility in 03/2021 with diagnoses including dementia. The resident's 05/01/22 through 05/23/22 MAR, TAR and physician's orders were reviewed and showed the following inaccuracies: * For the daily bowel monitoring parameters, the note directed staff to administer Miralax for no bowel movement in two days. The physician's order directed staff to administer Milk of Magnesia if the resident did not have a bowel movement in two days; * The directions to staff for the bisacodyl tablets stated, "Step 2" but the order note stated, "This is Step 1 of the Bowel Protocol. If not relieved in 24 hours, go to step 3;" * Milk of Magnesia was listed as "Step 1" and directed staff to administer the medication in three days if the resident had not had a bowel movement; and * The TAR reflects bisacodyl suppository to be "Step 3" and to administer if "constipation [was] not relieved with bisacodyl oral tablets," thus not having clear parameters for the four PRN bowel medications. The need to ensure the MARs were accurate and included clear parameters for administration of prescribed medications was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 05/25/22. They acknowledged the findings.

Z162/C310--Medication Administration 1} Health Service Director will audit the QMAR weekly to ensure the consistance of medication pass by Med Tech.  Weekly audits will include, PRN given, parameters followed, interventions offered before administer the medication, and audit for consistancy with following orders. 2} Med Tech training was held on 6/10/2022 to go over bowel protocol, following orders, following treatment as prescribe by PCP. 3} Health Service Director will conduct weekly audits and community Pharmacy (PharAmerica) quarterly audits. 4} Health Services Director

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident-specific parameters for PRN medications for 2 of 2 sampled residents (#s 4 and 5) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 10/2020 with diagnoses including Alzheimer's dementia. Resident 5's 08/01/22 through 8/30/22 MAR was reviewed during the survey. The following medications were documented as being administered at 8:00 am daily: * Calcium Carbonate; * Losartan; * Memantine; * Metformin; * Sertraline; and * Vitamin D3. The following medication was documented as being administered at 7:00 am daily: * Levothyroxine. In an interview with Staff 6 (MT) on 08/31/22 she reported that the resident slept late and that morning medications were regularly given between 10 am and 11 am. The need to ensure MARs were accurate was discussed with Staff 1 (Administrator) on 08/31/21. She acknowledged the findings. 2.  Resident 4 was admitted to the facility in 08/2022 with diagnoses including Lewy body dementia. Resident 4's 08/01/22 through 08/31/22 MARs were reviewed and lacked resident specific parameters to guide unlicensed staff in the following areas: *Acetaminophen 325mg 1 tablet PRN pain; *Acetaminophen 325mg 2 tablets PRN pain; *Morphine Sulfate 5mg PRN moderate pain; and *Polyethelene Glycol PRN constipation. Resident specific parameters for pain and bowel care medication was reviewed with Staff 1 (Administrator) and Staff 12 (Health Services Director) on 08/31/22 at 4:10 pm.  Staff acknowledged the findings.

C310--Medication Administration 1} Health Service Director and Resident Care Coordinator will audit the QMAR weekly to ensure the consistance of medication pass by Med Tech.  Pre popping is unacceptable. Med Tech is to follow the medication pass according to the time stated in the MAR. Weekly audits will include, PRN given, parameters followed, interventions offered before administer the medication, and audit for consistancy and accuracy with following orders. 2} Med Tech training was held on 9/8/2022 to go over bowel protocol, following orders, following treatment and medication orders as prescribe by PCP. 3} Health Service Director and Resident Care Coordinator will conduct weekly audits and community Pharmacy (PharAmerica) quarterly audits. 4} Health Services Director and RCC

Based on interview and record review, it was determined the facility failed to conduct drills every other month and failed to include required components on fire drill records. Findings include, but are not limited to: Review of fire and life safety records for December 2021 through May 2022 identified the following: 1. Two fire drills had been completed during the six-month time frame reviewed. 2. Fire drill records lacked the following components: * Location of simulated fire origin; * Escape route used; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Evidence alternate routes were used during fire drills; and * Number of occupants evacuated. The need to ensure the facility conducted fire drills every other month and included documentation of all required components was discussed with Staff 1 (Administrator) on 05/24/22 at 2:00 pm. She acknowledged the findings.

Z142/C420--Fire and Life Safety: 1} Administrator will conduct unannouced Fire Drill every other month.  Fire and Life Safety training will be provided alternate months.  Fire Drills will be conducted for each shift, Day, Swing and NOC. Fire and Life Safety trainings will be held alter months at the all staff meetings.  Administrator updated the Fire Drill and Fire and Life Safety form to reflect the missing information provided by the State Surveyors.   2} Fire Drills will be conducted unannouced every other month by the Administrator.  This will include all three shift (Day, Swing, NOC) These Fire Drills will include the following a.Date and time of day, b. Location of simulated fire orgin, c. The escape route used, d. Problems encountered and comments relting to residents who resisted or failed to participate in the drills, e. Evacustion time period needed. f. staff members on duty and participating, g. number of residents evacuated.Fir 3} Fire Drills every other month, Life and safety training on alternate months. 4} Administrator

Based on interview and record review, it was determined the facility failed to re-instruct residents 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. Findings include, but are not limited to: On 05/24/22, this surveyor met with Staff 1 (Administrator) to review the facility's process and documentation for instructing residents on basic safety procedures. Staff 1 stated the facility did not have a process for providing instruction to residents at least annually in fire and life safety procedures. Staff 1 stated she understood the requirements and would be able to implement a procedure for providing instruction to residents quickly.

Z142/C422-Fire and Life Safety Training for Residents 1} Administrator will meet with new resident and family members to go over fire drills and fire and life safety procedures.  Resident handbook will be updated to include the fire drill procedure and Fire and Life Safety procedure.   2} The Administrator will audit training binder on a monthly basis to make sure that any new resident/s moving in is/are educated with the procdure.  The Administrator will conduct Fire and Life Safety training 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.  Will invite families to attend if avaialble.  Training can be in form of watching a Fire and Life Safety Video or a guest speaker from the Fire Department. 3} The Administrator will conduct this for every new move in and annually. 4} Administrator

Based on observation and interview, it was determined the facility failed to ensure the grounds were orderly and free of litter and refuse, and garbage was stored in closed containers. Findings include, but are not limited to: The facility grounds were toured on 05/25/22. There was refuse including cardboard boxes and a recliner observed in the front of the building, to the right by the smoking area. The need to ensure the building exterior was kept orderly and free of litter and refuse was discussed with Staff 1 (Administrator) on 05/25/22. She acknowledged the findings.

Z142/C510-Gene Building Exterior 1} Administrator will walk the outside of the community to make sure it is free of trash.  Administrator will check to make sure the trash area is clean and free of trash on the ground.  Administrator will make sure that the overall look of exterior of the community is clean, clear and well kept daily. 2} Administrator will conduct walk through daily and report any exterior wear and tear or damages to the owner 3} Administrator will monitor daily through walk through when in the community.  Other days when not in the community will observe through outside cameras. 4} Administrator * All items observed during the survery were removed on 5/25/2022. * Remainder of the fence was put up by the neighbor on 6/6/2022

Based on observation and interview, it was determined the facility failed to ensure the design of the RCF supported special resident needs relating to the installation of handrails at one or both sides of resident-use corridors. Findings include but are not limited to: The interior of the building was toured on 05/25/22 at 11:50 am. The corridor between the medication room and the conference room was lacking a handrail. The need to ensure handrails were accessible to residents along corridors was discussed with Staff 1 (Administrator). She acknowledged the findings.

Z142/C511-General Building Interior 1} Administrator will conduct daily walk through of the community to make sure that common areas (Lobby, Living room, Dining room and hall ways are visible and accessible to residents and visitors when entering the doors to the main exntrace at the community. 2} Administrator will communicate to staff to report any damages or things out of place so that Administrator can follow up, document and communicate to the owner of a plan to replace or fix. 3} Administrator will conduct daily walk through.  Report the finding to owner on a weekly basis. 4} Administrator * The side rail was installed on 6/16/2022 by the corridor between med room and the conference room.

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: Observation of the facility on 05/23/22 through 05/25/22 revealed: * Gouges in baseboards throughout the facility; * Scuffs and gouges along the corridors; * The bottom of multiple room doors were scuffed; * Multiple door frames had scuff marks on them; and * Room 4's door frame had exposed wood that was rough to the touch. The findings were reviewed with Staff 1 (Administrator) on 5/25/22. She acknowledged the findings.

Z513/C513-Doors, Walls, Elevators, Odors 1} Administrator will conduct a daily walk through of the community to check for wear and tear of the whole interior of the community.  Any findings is to report to the owner for a plan to repair. 2} Administrator will follow through with the daily walk through report and report findings to the owner on a weekly basis.  Owner will reach out to the contract maintenance staff to assist with getting repairs done. 3} Daily walk through will report to owner on a weekly baisis unless it is an ememrgency that is needed to fix immediately. 4} Administrator * Touch up paint was completed 5/27/2022

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 C 240, C 420, C 422, C 510, C 511 and C 513.

Z142 Refer to C240, C420, C422, C510, C511, and C513

Based on interview and record review, it was determined the facility failed to ensure all pre-service orientation was completed and documented for 1 of 1 newly hired direct care staff (# 7) and annual training was completed and documented for 3 of 3 long-term direct care staff (#s 6, 9 and 10) whose training records were reviewed. Findings include, but are not limited to: Training records were reviewed on 05/24/22. Staff 7 (MT/CG) was hired on 02/15/22. Review of the facility training records revealed Staff 7 did not complete the following pre-service and competency training before providing care and services independently: * Abuse reporting requirements; * Environmental factors that are important to resident's well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); * How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment; * The use of supportive devices with restraining qualities in memory care communities;   * Role of service plans in providing individualized care; * Changes associated with normal aging; * Conditions that require an assessment, treatment, observations and reporting; and * Other duties as applicable (Med pass, treatments). Staff 1 (Administrator) reported on 05/25/22 the topics would be addressed and the competencies demonstrated would be documented later that evening when Staff 7 returned to work. Staff 6 (MT/CG) was hired on 12/07/19, Staff 9 (CG) was hired on 01/11/19 and Staff 10 (CG) was hired on 09/16/19. Review of the facility training records revealed the following: * Staff 6 did not complete six hours of annual training related to dementia care; * Staff 9 did not complete 16 hours of annual training related to provisions of care in CBC, including six hours related to dementia care; and * Staff 10 did not complete ten hours of annual training related to provisions of care in CBC. The need to ensure all newly hired staff completed pre-service orientation and all veteran staff completed 16 hours of annual training was discussed with Staff 1 who acknowledged the findings.

Z155-Staff Training requirements 1} Staff members 6, 7, 9 and 10 will receive Oregon Healthcare Partner training and Compliance training by compliance date.  Competency checklists have been updated to include missing elements of training. 2} Facility will utilize trainings thare in Compliance with OAR to ensure staff receive training on relevant topics.   Administrator and RCC will go through the Orientation process with all new hires.  Provide Dementia training (through training video, Oregon Healthcare Partners (Free Training), Monthly staff inservice by Administrator or schedule vendor to provide training on relevant topics to make sure that our staff are properly trained. 3} Quarterly competency evaluations will be conducted to determine knowledge and understanding. 4} Administrator and Resident Care Coordinator

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 sampled newly-hired staff (#13) had documentation of completed orientation, pre-service dementia training and demonstrated competency in all required areas prior to working independently with residents.  This is a repeat citation.  Findings include, but are not limited to: Staff 13 (CG), hired 08/03/22, training records were reviewed with Staff 1 (Administrator) on 08/31/22 and revealed the following: a.  There was no documented evidence Staff 13 had completed orientation prior to performing any job duties in the following areas: *Resident rights and values of CBC care; *Abuse reporting requirements; *Infectious Disease Prevention; and *Fire safety and emergency procedures. b.  There was no documented evidence Staff 13 completed the pre-service dementia care training prior to providing care and services independently. c.  There was no documented evidence Staff 13 demonstrated competency in required areas prior to providing care and services independently. During an interview with Staff 1 on 08/31/22, she verified the lack of training documentation.  Staff 1 stated the employee was a re-hire and new hire paperwork had been completed, however was unable to provide written documentation.

Z155-Staff Training requirements 1} Staff members and new hires will receive Oregon Healthcare Partner training and Compliance training by compliance date.  Competency checklists have been updated (using the CBC Caregiver Training Record Review) to include missing elements of training. 2} Facility will utilize trainings that are in Compliance with OAR to ensure staff receive training on relevant topics.   Administrator and RCC will go through the Orientation process with all new hires.  Provide Dementia training (through training video, Oregon Healthcare Partners (Free Training), Monthly staff inservice by Administrator and RCC or schedule vendor to provide training on relevant topics to make sure that our staff are properly trained. Staff members given information on how to access Oregon Healthcare Partners with the list of required classes to complete before start of emplyment.   3} Quarterly competency evaluations will be conducted to determine knowledge and understanding. 4} Administrator and Resident Care Coordinator

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. Findings include, but are not limited to: Refer to C 260, C 270, C 303 and C 310.

Z162-Compliance with Rules Health Care Refer to C260, C270, C303, and C310

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 303 and C 310.

Z162 Refer to C303 and C310

2. Resident 1 was admitted to the facility in 03/2021 with diagnoses including dementia. Resident 1's current service plan was reviewed during survey. The service plan lacked an accurate, individualized nutrition and hydration plan, including information related to the resident's food and fluid preferences. The need to develop individualized service plans addressing residents' nutrition and hydration needs and preferences was discussed with Staff 1 (Administrator), and Staff 2 (Heath Services Director) on 5/25/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in the service plan for 2 of 3 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: 1.  Resident 2 was admitted to the facility in 06/2019 with diagnoses including dementia and history of stroke.   Resident 2's current service plan was reviewed during survey. The service plan lacked an individualized nutrition and hydration plan, including information related to the resident's food and fluid preferences. The need to develop individualized service plans addressing residents' nutrition and hydration needs and preferences was discussed with Staff 1 (Administrator), and Staff 2 (Heath Services Director) on 5/25/22. They acknowledged the findings.

Z163-Nutrition and Hydration 1} Health Services Director will include a nutrition and hydration schedule to each resident's service plan. Initial evaluation form has been updated to asked more detail questions about favorite drinks (any juice, coffee, tea, soda pop (what kind) resident preferences.  Resident Social profile update to add resident likes and dislikes in regards to food and drinks. Information collected from these two tools will help develop a more detailed and personlize service plan for staff to read and understand.   2} Facility will assign caregiver to specific residents daily to ensure that hydration and nutrition schedules are offered to each resident during waking hours. 3} Health Service Director will evaluate nutrition and hydration schedules monthly and implement any changes as needed. 4} Health Service Director

Based on observation, interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 3 of 3 sampled residents (#s 1, 2 and 3) whose records were reviewed. Findings include, but are not limited to: Though Resident 1, 2 and 3's service plans offered some information about the resident's interests, the facility had not fully evaluated the resident's: * Current abilities and skills; * Physical abilities and limitations; and * Adaptations necessary for the resident to participate. There were no specific activity plans which detailed what, when, how and how often staff should offer and assist the residents with individualized activities. The need to ensure each resident was evaluated and an individualized activity plan was developed was reviewed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 05/25/22. They acknowledged the findings.

Z164-Activities 1} Resident Social profile update to include the following: a. Past and current interests, b. Current abilities and skills, c. Emotional and social needs and patterns, d. Physical abilities and limitations, e. Identification of activities for behavioral interventions, f. Adaptations necessary for the resident to participate, g. Schedule and planned events (entertainments, outings) h. Activities for enjoyments or those that may help diffuse a behavior, i. Activities that encourage positive relationship between residents and staff (life story, reminiscing, music) j. Sensory stimulation activities, k. Physical activities that enhance or maintain a resident's ability to ambulate or move, l. Outdoor activities that interest a resident. 2} Administrator will meet with Activitiy Director to go over the Resident Social Profile and plan activities appropriate for each resident as a group or individual.  Resident Social Profile will be given to Health Service Director to implement the information collected into resident Service Plan. 3} Monthly audits will be conducted by Administrator and also on any new admission. 4} Administrator

Based on interview and record review, it was determined the facility failed to provide an individualized service plan for behavioral symptoms that negatively impacted the resident or others in the community for 2 of 2 sampled residents (#s 1 and 3) with documented behaviors. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 03/2021 with diagnoses including dementia. Resident 1's record documented behaviors including agitation, yelling and putting himself/herself on the floor for attention. An interview with Staff 10 (CG) on 05/25/22 at 1:09 pm revealed the service plan was not reflective of the interventions that were more successful with the resident. She identified the resident enjoyed any activity and taking the resident to the restroom. Staff 10 stated the resident responded well to constant one on one attention, but staff didn't have the time to be able to do that. She also stated that the intervention for staff to let the resident rest in his/her room was not safe due to being a high fall risk. 2. Resident 3 was admitted to the facility in 03/2022 with diagnoses including dementia. The resident's service plan, dated 04/14/221, did not address any behaviors, thus lacked individualized interventions to assist staff in minimizing the negative impact of the behaviors. Staff 10 confirmed Resident 3's behaviors included refusing care. The resident preferred some staff over others, so in order for the resident to consent to care (e.g. assistance with ADLs), staff would switch to someone the resident responded to positively. The need to develop individualized behavior plans for residents with behavioral symptoms was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 05/25/22. They acknowledged the findings.

Z165--Behavior 1} Initial Evaluation form updated to add more detail questions in regards to behaviors and interventions.  Health Service Director is to collect as many information about past behavior and recent behaviors with solutions that was successful in the past.  Health Service Director is to develop his/her service plan under section Emotion Health/Behavior Issues, plan interventions with a behavior presented in the past and/or recent behaviors.  List each behavior with interventions that are successful and interventions that were not successful.   2} An inservice was held on 6/10/2022 to train staff on resident behaviors, what intervention works and what interventions did not work.  Every resident reacts different.   3} Monthly inservices for all staff on relevant topics to resident behaviors, monthly service plan audits. 4} Administrator and Health Service Director

Based on 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 C 303, C 310, Z 155 and Z 162.

C455-Inspections & Investigations 1) Administrator and RCC will make sure the information needed is available at all times. 2) Administrator and RCC will make sure that all records, documentations, self report, IR, resident SP, application procedures and other necessary activities are made avaialble to the department upon request. Accuracy and consistency of reporting concerns to the proper autnority to rule out any abuse and neglect in the community.  Consistency of communications with PCP, families and third party agencies on a daily basis. 3)Administrator and RCC will audit records on a day to day basis to make sure that all information gathered, documented and follow through. 4) Administrator and RCC

The findings of the change of ownership survey conducted 05/23/22 through 05/25/22 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living 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 revisit to the re-licensure survey of 05/25/22, conducted 08/31/22, 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. 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 05/25/22, conducted 12/01/22, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Division 57 for Memory Care Communities.