Markham House

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 Seniors and People with Disabilities (SPD) office unless an immediate facility investigation reasonably concluded and documented that the physical injury was not the result of abuse, for 2 of 2 sampled residents (#s 3 and 4) who had injuries of unknown cause. Findings include but are not limited to: Resident 4 was admitted to the facility in 4/2019 with diagnoses including dementia, major depression, and a neurocognitive disorder. Review of the resident's clinical record, including progress notes from through 11/01/25 through 02/09/26 identified the following: * 11/09/25 - “med tech noted dark bruising to back of resident’s left hand. No other new bruising noted during this check.” * 12/12/25 - “It was brought to this RN attention that [Resident 4] has bruises on [his/her] hands. [S/he] has two on [his/her] left and one on [his/her] right. They are deep purple in color. No S/SX of infection. [S/he] is not sure how it happened.” * 12/19/25 - “it was noted [s/he] has some new bruising going up [his/her] left arm. They are scattered up [his/her] forearm. Again, [s/he] has no idea of how they happened.” These bruises represented injuries of unknown cause which were required to be reported to the local SPD office unless an immediate facility investigation reasonably concluded and documented that the physical injury was not the result of abuse. During an interview on 02/11/26 at 1:45 pm, Staff 1 (ED) reported there were no documented investigations completed for the above incidents. There was no documented evidence the facility immediately investigated the resident’s bruises to rule out suspected abuse or neglect, and there was no documented evidence the facility reported the incidents to the local SPD office. The need to ensure all incidents and injuries of unknown cause were immediately investigated to rule out suspected abuse, or reported to the local SPD office if abuse could not be ruled out, was discussed with Staff 1 (ED), Staff 2 (Wellness Director/RN), and Staff 3 (RCC) at 11:45 am. They acknowledged the findings. Survey requested the facility report the above incidents to the local SPD office. Confirmation that the incidents were reported was received on 02/12/26 at 8:10 pm. 2. Resident 3 was admitted to the facility in 01/2026 with diagnoses including traumatic subdural hemorrhage. Review of the resident's clinical record, including progress notes from through 01/12/26 through 02/12/26, identified the following: * On 01/19/26 staff documented in a progress note that Resident 3 “has visible bruising to the left side of [his/her] back.” * On 02/05/26 staff transcribed a hospice visit note into a progress note which read, “Bruises noted to left leg and right hip. Scabs noted all over legs and bruising on arms.” These conditions represented injuries of unknown cause which were required to be reported to the local SPD office unless an immediate facility investigation reasonably concluded and documented that the physical injury was not the result of abuse. There was no documented evidence the facility immediately investigated the injuries and documented how it reasonably concluded the injuries were not the result of abuse. The facility had not reported the injuries to the local office. The requirements for responding to an injury of unknown cause were reviewed with Staff 1 (ED), Staff 2 (Wellness Director/RN), and Staff 3 (RCC) on 02/12/26 at 11:50 am. They were unable to provide documentation of an investigation of the injuries of unknown cause. The surveyor directed the facility to report the incidents to the local office. Confirmation that the incidents were reported was received on 02/12/26 at 8:10 pm.

1. The following actions will be taken to correct the violation: a. Incident reports and investigations for resident 4's bruising on back on resident's left hand, bruises on left& right hand and bruising on her left was completed and self-report was sent Multnomah APS office. b. Incident reports and investigations for resident 3's 2 bruising on his back, left leg/ right leg & scabs all over legs & bruising on arms was completed & self-report was sent local SPD /Multnomah APS office. 2. How will the system to be corrected to this violation will not happen again? Training will be provided to all care staff and Med-Techs on the proper procedure for reporting new skin issues or bruising to the RCC/RN. Med-Techs will document any newly observed skin issues or bruising in the 24-hour report book to ensure timely review and follow-up by the RCC/RN. The RN/RCC will also review outside provider notes on a daily basis to ensure awareness of any newly identified skin issues or bruising and to initiate appropriate investigation and follow-up as needed. When there are new skin issues/ tear/ wounds and bruising RCC/RN will immediately do incident report and investigation and follow-ups to rule out abuse within 24-48 hours. If there are suspected abuse, injury of unknown cause will be reported to local SPD. 3. How often will the area needing correction be evaluated? The systems to ensure that Incident Reports and investigations are reviewed there will be a visual list of Incident Reports and be reviewed in the bi weekly clinicals that will be reviewed by Wellness Director RN, RCC and Executive Director. 4.Who will be responsible to see that the corrections are completed? The Wellness Director (RN) and Executive Director will be responsible for ensuring that the corrections are completed and monitored.

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

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of the resident’s needs, provided clear direction regarding the delivery of services, and were implemented, for 2 of 5 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to: Resident 1 was admitted to the facility in 05/2023 with diagnoses including coronary artery disease, diabetes and dementia. The resident’s clinical record from 11/05/25 to 02/09/26 was reviewed, observations were made, and interviews were conducted with the resident and staff. The following was identified: The service plan, dated 01/15/26, and 11/17/25 to 01/26/26 temporary service plans (TSPs), were not reflective of the resident’s current status and lacked clear instructions for staff in the following areas: a. During an observation of the resident’s room on 02/10/26 at 9:35 am, it was noted there was a half-length side rail and an air mattress on the bed. There was no information or instructions in the current service plan regarding the use of the side rail and air mattress. b. The current service plan indicated the resident had a catheter and included instructions for the catheter care. In an interview on 02/10/26 at 11:45 am, Staff 13 (MT/CG) reported the resident did not have a catheter at this time. The resident previously had a catheter, approximately two months ago, which was temporary and was no longer in place. c. The current service plan provided conflicting information regarding whether the resident required one- or two-person assistance for bathing. d. In an interview on 02/10/26 at 11:45 am, Staff 13 (MT/CG) reported the resident used a sensor to monitor his/her blood sugar level and staff changed the sensor every two weeks. However, the service plan did not include information about or care instructions for the blood sugar monitoring sensor. e. Review of the clinical record showed the resident received outside provider services - home health physical therapy and speech pathologist. However, the service plan did not provide information on these services, including who to contact and when. The need to ensure service plans were reflective of the resident’s status and provided clear direction to staff regarding the delivery of services was reviewed with Staff 1 (ED), Staff 2 (Wellness Director/RN), and Staff 3 (RCC) on 02/11/26 at 10:30 am. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 01/2026 with diagnoses including traumatic subdural hemorrhage without loss of consciousness, cerebral infarction, and weakness. The resident’s clinical record from 01/12/26 to 02/09/26 was reviewed, observations were made, and interviews were conducted with staff. The following was identified: The service plan, dated 01/12/26, and 01/18/26 to 02/02/26 temporary service plans (TSPs), were not reflective of the resident’s current status and lacked clear instructions for staff in the following areas: a. Review of the current service plan indicated that the resident required one-person assistance for transfers. During the acuity interview facility staff stated that Resident 3 required two-person assistance with transfers. During observations on 02/09/26 at 11:36 am and 02/11/26 at 11:58 am, two staff transferred the resident from the bed to the wheelchair. During an interview on 02/12/26 at 10:00am, Staff 11 and 12 (CGs) both confirmed that the resident required two staff for all transfers since the resident was admitted to the facility. b. The current service plan indicated the resident required one-person, full assistance with dressing, but could complete upper body dressing independently with verbal cueing. During observations on 02/09/26 at 11:36 am and 02/11/26 at 11:58 am it was noted that two staff were providing full assistance with dressing. In an interview on 02/12/26 at 10:00am, Staff 11 and 12 both confirmed that the resident required two-person assistance for dressing. c. The current service plan did not provide clear instruction for caregivers to apply barrier cream with every brief change or toileting. On 02/09/26 at 11:36 am observations were made during incontinence care. Staff 11 applied barrier cream. In interviews conducted on 02/12/26 with Staff 11, 12, and 13 (MT/CG) all confirmed that they applied barrier cream after toileting or incontinence care, per Hospice direction. d. The current service plan indicated that the resident was on aspiration precautions. There were no clear instructions to staff on what, how, or how often to monitor. In an interview on 02/11/26 at 1:58 pm, Staff 1 (ED) confirmed the service plan did not include clear instructions for staff. e. The current service plan indicated that the resident used multiple assistive devices for mobility and one-person transfers, including a walker, gait belt, and a wheelchair. In an interview on 02/12/26 at 10:00 am, Staff 11 and 12 both confirmed the resident did not use a walker or gait belt for transfers. The need to ensure service plans were reflective of the resident’s status and provided clear direction to staff regarding the delivery of services was reviewed with Staff 1 and Staff 2 (Wellness Director/RN) on 02/12/26 at 12:40 pm. They acknowledged the findings.

1. The following actions will be taken to correct the violation for each resident: 1. a. Resident 1's service plan, dated 2/10/26, has been reviewed and the service plan updated to reflect the the clear instructions to on how to use side rails & air mattress. b.Resident 1's service plan, dated 2/10/26, has been reviewed and service plan was updated and catheter and catheter care were taken out of the updated service plan. c. Resident 1s service plan, dated 2/10/26, was updated with clear instructions that bathing requires 1 person assist on bathing. d. Resident 1's service plan, dated 2/10/26, was updated with clear instruction on how to monitor blood sugar level & that staff changed sensor every 2 weeks and instructions on how to install sensor and care instructions for the blood sugar monitoring sensor. e. Resident 1's service plan, dated 2/10/26, has been updated that the resident is receiving Outside provider- home health PT and speech therapy, who are the providers and how often they visit. Resident 1's service plan have been updated with clear instructions to care staff on how to assist resident with his current care needs. Updates to Resident 1s service plan and directions for staff on how to provide and deliver services will be discussed at the upcoming All-Staff Meeting to allow for a clear understanding of responsibilities and forquestions and concerns to be discussed. 2.a Resident 3's service plan, dated 1/12/26, has been updated with clear instructions that resident requires 2 person assist with transfers. b. Resdient 3's service plan, dated 1/12/26, has been updated with clear instructions that resident require 2 person assist with dressing. c. Resident 3's service plan, dated 1/12/26, service plan has been updated with clear instructions that care staff are applying barrier cream after incontinence care/ toileting per hospice direction. d. Resident 3's service plan, dated 1/12/26, has been updated with clear instructions to the staff on what and how to monitor asperation precautions. e. Resident 3's service plan, dated 1/12/26, has been updated with what devices he uses and clear instructions on how to use & monitor current mobility devices. Resident 3's service plan have been updated with clear instructions to care staff on how to assist resident with his current care needs. Updates to Resident 3's service plan and directions for staff on how to provide and deliver services will be discussed at the upcoming All-Staff Meeting to allow for a clear understanding of responsibilities and forquestions and concerns to be discussed. 2.How will the system be corrected so this violation will not happen again? To prevent reoccurance, all service plans will be audited weekly by the RCC to reflect the residents current care and and provide clear direction to the staff. RCC will do a weekly audit on the service plan binder to ensure the most current service plan ius availabe to the staff and that stafff has read and signed the service plans that have been reviewed. A portion of all staff meeting will be set aside to discuss any concerns and questions about how to provide care services to any resident to ensure understanding of staff responsibilities. 3. How often will the area needing evaluation be corrected? The systems to ensure the thorough completion of quarterly service plans, including clear directions to staff, will be evaluated by Wellness Director RN and and the Excutive Director monthly during Monthly Wellness Meetings. 4. Who will be responsible to see that corrections are completed and monitored. The Executive Director and the Wellness Director RN will be responsible for overseeing that the above systems are in place and continously 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 411-054-0040 (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 determine and document what action was needed for a short-term change of condition, ensure weekly progress for short-term changes of condition was noted until the condition resolved, and the resident was monitored consistent with his or her evaluated needs and service plan, for 3 of 5 sampled residents (#s1, 2, and 3) with changes of condition requiring monitoring. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 05/2023 with diagnoses including lichen planus and candidal stomatitis. The resident’s clinical record was reviewed during the survey, and interviews were conducted with the resident and facility staff. The resident was identified with a significant weight loss on 09/02/25. The facility RN assessed the resident’s status, met with the resident, a family member, the ED, and the former chef, and developed a plan to address the weight loss. The new interventions were documented in the resident’s service plan and included providing a smoothie every breakfast, obtaining weekly weights, and offering the resident meal options that were soft in texture so as not to irritate the resident’s mouth. Observations during the survey indicated the resident did not receive any smoothies. In an interview on 02/10/26 at 12:07 pm, Resident 2 stated the facility initially provided smoothies for approximately the first few weeks but had rarely provided smoothies since then. In an interview on 02/10/26 at 10:15 am, Staff 7 (Kitchen Chef/Director) stated the kitchen made bottles of Ensure (protein supplement) available and staff could take them as needed for residents. Staff 7 did not make smoothies for Resident 2. Staff 7 said there were a variety of soft foods any resident could request from the facility’s menu. In an interview on 02/10/26 at 2:20 pm, Staff 13 (MT/CG) stated she did not always make a smoothie for Resident 2. Staff 13 said there was no procedure for documenting when Resident 2 was given a smoothie. The reports that Resident 2 had not been receiving the smoothies each morning per the service plan were discussed with Staff 2 (Wellness Director/RN) on 02/10/26 at 2:30 pm. She stated she was not aware that staff were not providing the smoothies as service planned. She acknowledged this would explain why the resident had not regained all the lost weight yet. She said the plan had been developed with the previous Kitchen Director and said she was unsure whether Staff 7 had been informed of the weight loss interventions, including providing the smoothies. She said she would schedule a meeting with the resident, family, RCC, and Staff 7 to review the weight loss plan and update it as needed. The facility failed to monitor the service planned interventions to ensure they were being implemented and were effective. The need to ensure the resident was monitored consistent with his or her evaluated needs and service plan was reviewed with Staff 1 (ED), Staff 2, and Staff 3 (RCC) on 02/11/26 at 2:30 pm. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 01/2026 with diagnoses including traumatic subdural hemorrhage. The resident’s clinical record was reviewed during the survey, and interviews were conducted with the resident and facility staff. The following was identified: a. Upon move-in, the facility placed the resident on “Alert Charting” and instructed staff to “monitor/observe how resident is adjusting to community.” Review of the subsequent Alert Charting documentation by staff indicated the staff did not document on how the resident was adjusting to the community as instructed. b. On 01/19/26, staff documented bruising to the left side of the resident’s back and on 01/30/26 staff documented the resident sustained a skin tear to the right lower leg/knee. In an interview on 02/12/26 at 11:50 am, Staff 2 (Wellness Director/RN) and Staff 3 (RCC) acknowledged no specific instructions had been developed and documented for monitoring the injuries. They acknowledged no weekly progress was noted regarding the conditions or whether they were resolved. The facility failed to determine and document what action was needed for the resident following these short-term changes of condition and failed to ensure weekly documentation of the conditions until they were determined to have resolved. The need to ensure actions/interventions were determined and documented following a change of condition, and the progress of the condition was noted at least weekly until resolved, was reviewed with Staff 1 (ED), Staff 2, and Staff 3 on 02/12/26 at 11:50 am. They acknowledged the findings. 3. Resident 1 was admitted to the facility in 05/2023 with diagnoses including coronary artery disease, diabetes, and dementia. The resident’s clinical records, including 01/15/26 service plan, 11/07/25 through 01/26/26 temporary service plans, and 11/05/25 through 02/09/26 charting notes, were reviewed. Staff interviews were conducted which indicated the resident experienced multiple changes in condition. The following was identified: * On 11/10/25, the resident was sent to the emergency department and admitted to the hospital due to low oxygen saturation and low heart rate; * On 12/10/25, the resident’s diet was changed to thin liquids; * On 12/14/25 and 12/15/25, the resident’s right leg was swollen. The resident had an urgent care visit and was prescribed an antibiotic to treat the leg; * On 12/19/25, the resident was found on the bathroom floor; and * On 01/24/26, the resident was sent to the emergency department and returned to the facility on 01/26/26. The facility developed the temporary service plans for the above changes in condition to inform staff what to monitor and document, and staff initiated progress notes. However, there was no documented evidence the facility monitored the resident’s conditions until resolution. In an interview on 02/10/26 at 12:35 pm, Staff 3 (RCC) acknowledged the facility did not document on the progress of the resident’s changes of condition until the conditions were resolved. The need to ensure the facility monitored and documented weekly progress in the resident’s record until the condition resolved was discussed with Staff 1 (ED), Staff 2 (Wellness Director/RN), and Staff 3 on 02/11/26 at 10:30 am. They acknowledged the findings.

The following actions will be taken to correct the violation for each resident: 1 a. Resident 2's weight loss intervention having shake every breakfast was updated by adding monitoring in EMAR as a treatment that Med-techs will be checking daily if she received shakes, if she has not received on Med-tech will remind the kitchen. The kitchen staff was given an updated list of specialized diets. Clear and specific directions have been provided to staff via written documentation in EMAR, in the resident's service plan & the kitchen has given clear instruction about updated specialized diet list for Resident 2. 2 a. Resident 3's alert charting . Wellness RN and RCC will update and give clear instructions when a resident is on alert charting what to monitor and what to document specifically. Re-training on Med-techs on documenting alert charting. b. Resident 3's injuries was re-assesed by Wellness Director RN and most current treatment and monitoring was added Treatment Administration Record on EMAR. Registered Nurse will continue to evaluate, monitor, and document on Resident 3's injury progression and effectiveness of current interventions and ordered treatments weekly until resolved. The Registered nurse will provide education to all care staff members on what signs and symptoms to monitor for, when to alert a licensed nurse of concerns, how to alert a licensed nurse of concerns, and when the wounds need urgent medical attention. Clear and specific directions will be provided to staff via written documentation in EMAR and in the resident 3's service plan. Registered Nurse will continue to monitor of any potential signs that the injuries has progressed to a significant change of condition. c. Resident 1's service plan was updated including previous significant change of condition low oxygen and low heart rate, edema on his legs and multiple visits to hospital due to low oxygen issues. Registered Nurse will continue to evaluate, monitor, and document on Resident 1's oxygen issues and effectiveness of current interventions and ordered treatments weekly until resolved. The RN will provide education to all care staff members on what signs and symptoms to monitor for, when to alert a licensed nurse of concerns, how to alert a licensed nurse of concerns, and when resident needs urgent medical attention. Clear and specific directions will be provided to staff via written documentation in EMAR and in the resident 3's service plan. Registered Nurse will continue to monitor of any potential signs that conditon has progressed to a significant change of condition or until condition has resolved. How will the system be corrected so this violation will not happen again? A visual list of residents with skin issues, wounds, falls, changes of condition, and re-admission from hospitalization will be placed on a communication board in the Wellness Office, along with the most recent date of evaluation. This list of residents will be discussed during weekly clinical meetings with the RCC, Wellness Director (RN), and Executive Director. Any updates to resident-specific interventions will be communicated to care staff by providing clear instructions via the service plan. Weekly clinical meetings will include reviewing TSPs, outside provider notes, skin sheets, progress notes, and 24- hour alert logs to identify any changes of condition or wounds that have not yet been addressed by the licensed nurse. 3.How often will the area be needing correction be evaluated? The effectiveness of the visual list of residents via a communication board and the discussions of changes of conditions during bi- weekly clinical meetings will be reviewed by the Wellness Director (RN) and the Executive Director monthly during monthly Wellness Management meetings. 4. The Executive Director and th Wellness Director RN will be resposible for ensuring that the correction are completed and monitored.

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 411-054-0050(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 maintain infection prevention and control protocols to provide a safe and sanitary environment for 1 of 1 sampled resident (#3) whose personal care was observed. Findings include but are not limited to: Resident 3 was admitted to the facility in 01/2026 with diagnoses including traumatic subdural hemorrhage. Observations were made during the survey to determine adherence to universal precautions for infection control. On 02/11/26, at 11:50 am, the surveyor obtained permission and observed Staff 13 (MT/CG) and Staff 15 (CG) provide incontinence care to Resident 3. During the observation, Staff 13 and Staff 15 failed to change gloves after removing a soiled incontinence product and wiping urine from Resident 3's perineum and before handling clean items. Staff continued to use the same gloves while touching the resident’s clothing and wheelchair during transfer from bed to chair. Staff 13 then began to change the bed, tossing linens onto the roommate’s bed (spouse) to change the sheets. Staff 15 took Resident 3 into the bathroom to assist with personal hygiene, oral care, and grooming. In an interview immediately following the observation, Staff 13 and 15 acknowledged they both forgot to change their gloves after handling soiled items and before handling clean items. The need to ensure staff consistently used universal precautions was discussed with Staff 1 (ED), Staff 2 (Wellness Director/RN), and Staff 4 (Business Office Manager) on 02/12/26 at 12:50pm. They acknowledged the findings.

1. The following actions will be taken to correct the violation for each resident: Resident 3 on 3/6/26 All staff in-service on Universal precautions: proper handling use of gloves after handling soiled items and before handling clean items. All staff were assigned to take About Infection Control and Prevention training through Oregon Care Partners-Relias video. 2 How will the system be corrected so this violation will not happen again? Every other month, universal precautions will be reviewed/in-serviced at monthly all-staff meetings. 3. How often will the area needing correction be evaluated? RCC / OR Wellness Director RN to complete competency for all associates. Additionally, random audits of proper hand hygiene of at least 3 staff weekly x2 months then at least monthly. All new staff will demonstrate competency univeral precaution and proper use of gloves. 4. Who will be responsible to see that the corrections are completed/ monitored? The Executive Director and th Wellness Director RN will be resposible for ensuring that the correction are completed and monitored.

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 observation, interview, and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 1 of 5 sampled residents (#1) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 05/2023 with diagnoses including coronary artery disease, diabetes, and dementia. Resident 1's physician’s orders, dated 09/28/25 and 01/26/26, and MAR/TARs, dated 01/01/26 through 02/09/26, were reviewed. The following was identified: a. The resident had a physician's order to administer finasteride 5 mg for bladder retention daily. The MAR showed 14 occasions staff documented the medication was not administered because it was unavailable. b. The resident had a physician's order to apply Nystatin powder three times daily. The TAR showed two occasions staff documented the treatment was not applied because it was unavailable. The need to ensure all medication orders and treatments were carried out as prescribed was discussed with Staff 1 (ED), Staff 2 (Wellness Director/RN

1. The following actions will be taken to correct the violation: a. Resident 1 Med techs will have an in-serviced on documentation and Notification to RCC/ Wellness Director RN of any medication they have not received within 48 hours of reorder. In-service includes medication ordering, follow-up, documentation, notifying physicians for missed medications. b. Resident 1 Nystatin. Med techs will have an in-serviced on documentation and Notification to RCC/ Wellness Director RN of any medication they have not received within 48 hours of reorder. In-service includes medication oredering, follow-up, documentation, notiying physicians for missed medications. 2. EMAR dashboard report for Exceptions - order unavailable, missed meds and order expring soon will be printed daily and be reviewed by Med-tech and RCC after each shift, follow-up to be documented in the chart notes. 3. RCC and/ or Wellness Director RN will be reviewing at least 2x a week EMAR dashboard during clinical meeting. 4.The Executive Director and the Wellness Director RN will be responsible for ensuring that the corrections are completed and monitored.

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 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber.

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused consent to orders for 2 of 2 sampled residents (#s 4 and 5) who had documented medication and treatment refusals. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 4/2019 with diagnoses including dementia, major depression, and neurocognitive disorder. The resident's 01/01/26 through 02/09/26 MARs and all physician orders were reviewed. On 02/02/26, the resident was documented as refusing: * Betamethasone (corticosteroid) .05% ointment; * Minocycline (antibiotic) 100 mg caplet; * Prescription anti-itch lotion (anti-inflammatory); and * Valerian root (supplement) 500 mg capsule. There was no documentation that the facility notified the resident’s physician/practitioner of these refusals. During an interview on 2/11/26 at 2:45 pm, Staff 1 (ED) confirmed that she was unable to find documentation of notification. The need to notify the practitioner when a resident refused to consent to orders was discussed with Staff 1, Staff 2 (Wellness Director/RN), and Staff 3 (RCC) on 02/12/26 at 11:45 am. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 08/2024 with diagnoses including severe protein-calorie malnutrition. The resident's 01/01/26 through 02/09/26 MARs and all physician orders were reviewed. The MAR indicated Resident 5 refused multiple prescribed medications on: * 01/02/26; * 01/06/26; * 01/07/26; * 01/23/26; * 01/24/26; * 01/26/26; and * 02/05/26. There was no documented evidence the facility notified the resident’s physician/practitioner of these refusals. In an interview on 02/11/26 at 12:40 pm, Staff 2 (Wellness Director/RN) acknowledged that she was unable to find documentation of notification. The need to notify the practitioner when a resident refused to consent to orders was discussed with Staff 1 (ED), Staff 2, and Staff 3 (RCC) on 02/11/26 at 2:30 pm. They acknowledged the findings.

1. The following actions will be taken to correct the violation: a. RCC will review Resident 4 's MAR/TAR and alert her primary care physician (PCP) of any refusals for medications or treatments for the last quarter. In addition, the PCP's preference will be requested on how often they want to be alerted of medication refusals. This will be added to QuickMAR as an order for MedTechs to fax a list of medication refusals to the PCP at their preferred frequency. b. RCC will review Resident 5's MAR/TAR and alert her primary care physician (PCP) of any refusals for medications or treatments for the last quarter. In addition, the PCP's preference will be requested on how often they want to be alerted of medication refusals. This will be added to QuickMAR as an order for MedTechs to fax a list of medication refusals to the PCP at their preferred frequency. 2. All med-techs will have an in-service/ re-training for medication documentation including re-ordering medication, follow-up docmentation, notifying physicians for missed medications. The RCC will add physicians preference communication on EMAR for missed meds and will review this system 2x a week to ensure timely communications with the physicians. 3. The audit and review of alerting physicians of resident refusals to ordered medications or treatments will be reviewed by the Wellness Director RN and the Executive Director monthly during monthly Wellness Management meetings. 4.The Wellness Director RN and the Executive Director will be responsible for ensuring that the corrections are completed and monitored.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication.

Based on observation, interview, and record review, it was determined the facility failed to ensure an accurate Medication Administration Record (MAR) was kept for all medications that were ordered by a legally recognized prescriber and administered by the facility, for 2 of 4 sampled residents (#s 1 and 3) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 01/2026 with diagnoses including traumatic subdural hemorrhage without loss of consciousness, cerebral infarction, and weakness. The resident’s clinical record from 01/12/26 to 02/09/26 was reviewed, observations were made, and interviews were conducted with staff. The following was identified: a. On 02/03/26, the resident was prescribed PRN Ativan 0.5 mg every four hours as needed for nausea and/or agitation and/or anxiety, with parameters describing agitation and anxiety as evidenced by restlessness, calling out, fearful, inconsolable yelling, pacing, and/or physical aggression towards self or others. The resident was also prescribed morphine 5 mg every 15 minutes as needed for pain or shortness of breath, with parameters describing shortness of breath and pain as evidenced by labored respirations and/or respiratory rate greater than 25 per minutes or moderate pain as evidenced by grimacing, moaning, stiffening, or guarding of body parts, and/or pain rated 4-6 out of 10 on a verbal or PAINAD pain scale; the order also included instructions for when to notify the hospice RN. However, the parameters from the physician orders were not transcribed to the MAR. In an interview on 02/11/26 at 1:25 pm, Staff 13 (MT/CG) confirmed there were no clear parameters on the MAR to determine when to administer these medications to the resident. The facility failed to accurately transcribe the prescriber orders with resident specific parameters for PRN medications. b. The TAR directed staff to administer 2L per minutes oxygen via nasal cannula as needed for shortness of breath or if the resident’s oxygen saturation was below 92%. Staff monitored the resident’s oxygen saturation three times per day on the MAR. Between 02/01/26 and 02/09/26, the MAR indicated the resident’s oxygen saturation was below 92% on two occasions; however, there was no documented evidence that staff administered oxygen as prescribed. In an interview on 02/11/26 at 1:30 pm, Staff 13 (MT/CG) stated oxygen was administered when the resident had low oxygen saturations. The facility failed to accurately document on the MAR when PRN oxygen was administered. c. On 02/05/26 instructions were added to the MAR for staff to monitor Resident 3’s pressure reduction air mattress and ensure the bed and pressure redistribution functions were “on” every day and night. Between 02/05/26 and 02/08/26 staff documented daily in the morning and evening that they had checked the air mattress. During an observation by the RN surveyor, it was discovered that Resident 3 did not have a pressure reduction air mattress on his/her bed. The facility failed to ensure an accurate MAR because staff documented having checked an air mattress that did not exist. The inaccurate documentation regarding the air mattress was discussed with Staff 1 (ED) and Staff 3 (RCC) on 02/11/26 at 1:58 pm. The need to ensure that prescriber orders were transcribed accurately and that the facility accurately documented when treatments were administered was discussed with Staff 1, Staff 2 (Wellness Director/RN), and Staff 4 (Business Office Manager) on 02/12/26 at 12:40pm. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 05/2023 with diagnoses including coronary artery disease, diabetes, and dementia. Resident 1's 01/01/26 through 02/09/26 MAR and TAR were reviewed. The following was identified: * Staff were directed to administer vitamin C 1 to 2 tables daily. However, there were no clear parameters indicating when to administer one tablet versus two tablets. * Staff were directed to administer albuterol 2-4 puffs as needed for wheezing and shortness of breath. However, there were no clear parameters indicating when to administer two puffs versus four puffs. * There were multiple blanks on the MAR for routine wound care and oxygen therapy, where the facility failed to document whether the treatments were performed. The need for resident-specific parameters and instructions for PRN and scheduled medications and treatments, as well as MAR accuracy, were discussed with Staff 1 (ED), Staff 2 (Wellness Director/RN), and Staff 3 (RCC) on 02/11/26 at 10:30 am. They acknowledged the findings.

1. The follwing actions will be taken to correct the violation for each resident: 1. a. Resident 3's current PRN orders for Ativan and Morphine will be reviewed by the Wellness Director RN. The Wellness Director RN will add clear parameters to provide instructions for med-tech as to when to administer each medication for nausea and/or agitation and/or anxiety, and pain or shortness of breath as needed. b. Wellness Director RN will review Resident 3's treatment order for administering 2L oxygen and give clear instructions to med-tech when to adminster 2L oxygen as needed. c. Wellness Director RN will physically check DME equipment and will give clear instructions to care staff on how to accurately monitor equipment. 2.Resident 1's current order will be reviewed by Wellness Director RN and will add clear parameters for Vitamin C when to administer 1-2 tablets and Albuterol when administer 1-2 puffs as needed. Resident 1's MAR has multiple blanks for oxygen therapy & wound care, Wellness Director RN will be reviewing MAR weekly to ensure that med-techs are following treatments. 2. How often system will be corrected so this violation will not happen again? All med-techs for the community will receive a re- training conducted by Wellness Director RN regarding policies and procedures, including importance of parameters and clear instructions on how to administer PRN medications and treatments. The Wellness Director RN will review and audit the MAR/TAR and add clear parameters to multiple PRN orders for the same diagnosis. The Wellness Director RN will add clear parameters to all PRN medications and treatments as prescribed if needed. The Wellness Director RN will review all PRN orders and include parameters, if needed, prior to sending out the 90 day physician orders every quarter.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication.

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07

Based on interview and record review, it was determined the facility failed to ensure the use of supportive devices with restraining qualities were included in the resident’s service plan, evaluated on a quarterly basis, and the facility documented other less-restrictive alternatives were evaluated prior to the use of the device, for 3 of 3 sampled residents (#s 1, 3, and 5) who used a device with restraining qualities. Findings include, but are not limited to: During the acuity interview on 02/09/26, Staff 1 (ED) and Staff 2 (Wellness Director/RN) reported Residents 1, 3, and 5 used side rails on their beds. A side rail is considered a device with restraining qualities which requires an assessment, documentation, and inclusion in the resident's service plan. 1. Documentation regarding the use of a supportive device with restraining qualities was reviewed for Residents 1, 3, and 5. The form the facility used to assess the use of the device lacked documentation of what other less-restrictive alternatives had been evaluated prior to the use of the current device. The lack of this required documentation was reviewed with Staff 2 (Wellness Director/RN) on 02/11/26 at 12:40 pm. She acknowledged the form the facility used to document the use of the device lacked the required information. The lack of the required documentation was reviewed with Staff 1 (ED), Staff 2, and Staff 3 (RCC) on 02/11/26 at 2:30 pm. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 05/2023 with diagnoses including coronary artery disease, diabetes, and dementia and was observed to have a half-length side rail on the bed. Review of the resident's clinical record showed the assessment for the side rail use was completed by the RN on 06/27/25. However, it had not been reviewed quarterly as required. In an interview on 02/11/26 at 10:30 am, Staff 2 (Wellness Director/RN) confirmed the assessment for the side rail use had not been completed quarterly. The need to ensure any device with potential restraining qualities was evaluated on a quarterly basis was discussed with Staff 1 (ED), Staff 2, and Staff 3 (RCC) on 02/11/26 at 10:30 am. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 01/2026 with diagnoses including traumatic subdural hemorrhage without loss of consciousness, cerebral infarction, and weakness. Observations of the resident and the resident's room on 02/09/26 showed bi-lateral quarter-length side rails were installed at the head of the hospital bed and were in the up position while the resident was in bed. The side rails appeared intact and in good repair. Review of the resident's 01/12/26 service plan indicated the resident used the side rails for bed mobility and transfers. There was no information providing clear instruction to staff about the correct use and precautions related to the use of the side rails. The need to ensure clear instruction for the correct use and precautions for side rails was included in the resident’s service plan was discussed with Staff 1 (ED), Staff 2 (Wellness Director/RN), and Staff 4 (Business Office Manager) on 02/12/26 at 12:40 pm. They acknowledged the findings.

The following actions will be taken to correct the violation for each resident: 1. Wellness Director RN will be updating the form for Use of Supportive Devices with Restraining Qualities with adding a section of what other less-restrictive alternatives has been evaluated prior to the use of the current device. All residents using supportive devices will be re-assessed using the new form. Wellness Director RN will re-assess / update for use of ½ side-rails quarterly. Wellness Director RN will update service plan and provide clear instructions to care staff about the correct use and precautions related to the use of side-rails. 2. A visual list of residents with devices that have restraining qualities in the Wellness Department along with the most recent date assessed, the list will be discussed in the weekly clinical meeting with RCC and Wellness Director RN. 3. The list of residents with Use of Supportive with Restraining Devices be reviewed by the Wellness Director RN and the Executive Director monthly during monthly Wellness Management meetings. 4.The Wellness Director RN and the Executive Director will be responsible for ensuring that the corrections are completed and monitored.

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07

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 have a sufficient number of direct care staff to meet the fire safety evacuation standards during the night shift. Findings include, but are not limited to: The building had two floors where residents resided. There was a device stored on the second floor that was to be used to evacuate second floor residents who could not walk down the stairs in the event of an emergency. The “ABST (acuity-based staffing tool) Facility Entrance Questionnaire,” completed by Staff 1 (ED), was reviewed, and interviews with staff were conducted. The following was identified: * The community was currently home to 50 residents; * Six residents were noted to require the assistance of two staff with transfers; * Four of the six residents who required two-person assists required the use of a mechanical lift for transfers; and * Two residents who required the assistance of two staff and the use of a mechanical lift for transfers resided on the second floor. Staffing schedules indicated two direct care staff were assigned to the overnight (NOC) shift, from 10:00 pm to 6:00 am. In an interview on 02/12/26 at 8:40 am, Staff 1 confirmed the above information was accurate and at 11:02 am, Staff 1, Staff 2 (Wellness Director/RN), and Staff 3 (RCC) stated they were unaware how to use the assistive device to help residents down the stairs in the event of an emergency. They also stated they were unsure if two direct care staff were sufficient on the overnight shift to meet the fire safety evacuation standards. The need to ensure a sufficient number of direct care staff were present at all times to meet the fire safety evacuation standards during the overnight shift was reviewed with Staff 1, Staff 2, and Staff 3 on 02/12/26 at 11:14 am. They acknowledged the findings. Refer to C420 and C422.

1. The following actions will be taken to correct the violation for each resident: All staff will be trained to use the device for emergency evacuation using stairs. The Executive Director will be discussing with residents that use Hoyer lift if they are willing to move on the 1st floor if there are apartments that would be available. The community will be adding an additional care staff at NOC shift to be able to meet the fire safety evacuation standards. 2. Maintenance Director will train care staff every 2 months on all staff meeting on how to use device for emergency evacuation using the stairs. Aside from using ODHS ABST for staffing to accurately reflect current needs per shift based on information from each resident service plan and Executive Director will ensure a sufficient number of direct care staff are present at all times to meet the fire safety evacuation standards during the overnight shift. 3 Executive Director will evaluate with use of ABST and fire safety evacuation standards to define staffing needs once a month. 4.The Executive Director will be responsible for ensuring that the corrections are completed and monitored.

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) evaluations were completed before a resident moved in and no less than quarterly at the same time the resident’s service plan was updated, for multiple unsampled residents. Findings include, but are not limited to: On 02/09/26 the current resident roster with move-in dates was provided, and the facility’s ABST data was downloaded for review. Interviews with staff were conducted, and the following was identified: The current resident roster and ABST indicated there were 50 residents who currently resided at the community. a. The move-in dates noted on the resident roster were reviewed with each resident’s ABST evaluation creation date, and determined that at least 26 residents’ ABST evaluations were not completed prior to moving in. b. The facility ABST indicated 30 resident evaluations were not reviewed and updated at least quarterly. On 02/11/26 at 2:28 pm, the above was reviewed with Staff 1 (ED), and she reported she reviewed each resident evaluation at least quarterly; however, she acknowledged the manner in which she reviewed them did not reflect the date they were reviewed. The need to ensure the ABST evaluations were completed before a resident moved in and no less than quarterly at the same time the resident’s service plan was reviewed, was discussed with Staff 1, Staff 2 (Wellness Director/RN), and Staff 3 (RCC) on 02/12/26 at 11:14 am. They acknowledged the findings.

1. The following actions will be taken to correct the violation for each resident: a. RCC will enter new residents and in ABST 1-2 days prior to move-in to ensure that staffing accurately reflects current needs of residents per shift based on information on initial assessment for the new resident. b. RCC will update ABST simultaneously as the service plan is updated. 2. A visual list of service plan due dates and ABST update check list as service plans are reviewed and updated. For new resident an ABST update will be included in the new- move in checklist. 3. The list of service plan due dates reviewed by the Wellness Director RN and the Executive Director monthly during monthly Wellness Management meetings. 4.The Executive Director will be responsible for ensuring that the corrections are completed and monitored.

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 411-054-0070 (3-4) 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: (a) A review of their written position description with their job responsibilities. (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) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) 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. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable

Based on interview and record review, it was determined the facility failed to ensure 2 of 4 newly hired staff (#s 10 and 17) completed all required pre-service orientation training and 2 of 4 newly hired direct care staff (#s 9 and 10) completed the required pre-service dementia training. Findings include, but are not limited to: Staff training records were reviewed on 02/10/24 at 12:15 pm with Staff 4 (Business Office Manager), and the following was identified: a. There was no documented evidence Staff 10 (CG) or Staff 17 (MT/CG), hired 01/22/26 and 11/05/25, respectively, had completed one or more of the following required pre-service orientation topics prior to beginning their job responsibilities: * Resident rights and values of CBC care; * Abuse reporting requirements; * Fire safety and emergency procedures; * Written job description; * Infectious disease prevention training; * Home and Community-Based Services training; and * LGBTQIA2S+ training. b. There was no documented evidence Staff 9 (MT/CG) and Staff 10, hired 01/23/26 and 01/22/26, respectively, had completed one or more of the following pre-service dementia care training topics: * Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to behaviors; reducing use of antipsychotics; * Strategies for addressing social needs and engaging them in meaningful activities; and * Specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach. The need to ensure staff completed all required pre-service orientation training and pre-service dementia training was reviewed with Staff 1 (ED) on 02/10/26 at 12:57 pm. She acknowledged the findings, and no additional documentation was provided.

1. The following actions will be taken to correct the violation: a. Staff 10 & Staff 17 will have all required pre-service orientation topics: resident rights & values of CBC care, Abuse reporting requirements, Fire safety & emergency procedure, Written job description, Infectious disease prevention training, HCBS training and LGBTQIA2S+ training will be completed before working with residents and continuing their job duties. b. Staff 9 & Staff 10 will have required pre-service Dementia care training topics will be completed before working with residents and continuing their job duties. 2.Pre-service training for all current employees will be completed prior to beginning their job duties. For the newly-hired employees,all pre-service trainings including pre-service dementia, pre-service infection disease, resident rights and values of CBC, abuse reporting requirements, HCBS training, Fire & Safety emergency procedure, Providing Inclusive Care: Training for Oregon Long-Term Care Facility Staff and food handler's certification, will be required prior to beginning their job duties. 3. The system to ensure all employees have completed all required pre-service trainings prior to working with residents will be evaluated monthly during the monthly management meetings. RCC and BOM Director will do a monthly audit of pre-service training requirements to ensure compliance. 4.The Executive Director will be the responsible for ensuring the above corrections are completed and monitored.

OAR 411-054-0070 (3-4) 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: (a) A review of their written position description with their job responsibilities. (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) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) 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. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents.

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 newly hired direct care staff (#s 9, 10, and 17) demonstrated satisfactory performance in assigned job duties prior to working independently and 2 of 4 newly hired direct care staff (#s 10 and 17) completed first aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 02/10/24 at 12:15 pm with Staff 4 (Business Office Manager), and she reported staff identified below worked independently. There was no documented evidence Staff 9 (MT/CG), Staff 10 (CG), and Staff 17 (MT/CG), hired 01/23/26, 01/22/26, and 11/05/25, respectively, had demonstrated satisfactory performance within 30 days of hire and prior to working independently, in one or more of the following areas: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation, and reporting changes of condition; * Conditions that require assessment, treatment, observation, and reporting; * General food safety, serving, and sanitization; and * First Aid / abdominal thrust. The need to ensure direct care staff demonstrated satisfactory performance in any duty they were assigned and completed First Aid and abdominal thrust training within 30 days of hire was reviewed with Staff 1 on 02/10/26 at 12:57 pm. She acknowledged the findings and verified Staff 9, Staff 10, and Staff 17 worked independently. No additional documentation was provided.

The following actions will be taken to correct the violation: a. Staff 9, 10, and 17 will have all required trainings topics: Role of service plans in providing individualized care; Providing assistance with ADLs; Changes associated with normal aging; Identification, documentation, and reporting changes of condition; Conditions that require assessment, observation, and reporting; General food safety, serving, and sanitization; and First Aid / abdominal thrust within 30 days of hire completed before working with residents and continuing with their job duties. Staff 9,10 and 17 will have a care competency pass reviewed and signed by RCC and will have demonstrated satisfactory performance in their required job duties. 2. All current employees will be required to complete all the 30-day training requirements immediately. For newly-hired employees, all 30-day training requirements will be completed prior to their 30th day of hire. All Care staff will have required care competency pass and reviewed and signed by RCC. All med-tech will have completed medication pass training and demonstrated medication competency pass signed off by the HSD/Nurse. The Business Office Manager (BOM) and the RCC will be monitoring the care competency pass and medication pass competency for medication aides and 30-day training checklist for each employee. Those who have been unable to complete the 30-day training checklist prior to their 30th day of hire will be taken off the schedule until all required trainings has been completed. 3.The system to ensure that all employees have completed all required trainings prior to their 30th day of hire will be evaluated monthly during the monthly Management Meetings. The Executive Director and BOM director will do a monthly audit of the pre-service training requirements to ensure timely compliance. 4.) The Executive Director will be responsible for ensuring that the above corrections are completed and monitored.

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080.

Based on interview and record review, it was determined the facility failed to conduct and record unannounced fire drills every other month in accordance with the Oregon Fire Code (OFC) and, if unable to meet the applicable evacuation level, make an immediate effort to ensure the evacuation standard is met and failed to ensure fire and life safety instruction was provided to staff on alternate months from fire drills. Findings include, but are not limited to: On 02/10/26, fire drill and fire and life safety records for the previous six months were requested. a. Review of the documentation provided revealed there was no documented evidence the facility provided fire and life safety training for staff or conducted unannounced fire drills on alternate months. b. On 02/12/26, Staff 1 (ED), Staff 2 (Wellness Director/RN), and Staff 3 (RCC) reported the facility had a device to evacuate residents who resided on the second floor; however, they were unable to demonstrate how the device was used. The need to provide fire and life safety instruction to staff and conduct unannounced fire drills on alternate months and make an immediate effort to ensure evacuation standards were met, was reviewed with Staff 1, Staff 2 and Staff 3 on 02/12/26 at 11:14 am. They acknowledged the findings.

The following actions will be taken to correct the violation: a. Maintenance Manager will have required fire and life safety training for all staff and conduct unannounced fire drills on alternate months. b. Maintenance Manager will be conducting training for all staff on how to use device to evacuate residents on the second floor. All staff will be able to demonstrate that they are able to use the device for evacuation. 2. The Maintenance Manager will schedule an unannounced fire drill in TELS what shift it will occur and on alternating months what training he needs to conduct for fire life safety training. Twice a year training on how to use device for evacuation of residents on the second floor. 3. The system to keep resident safe will be evaluated once a month during monthly meeting management. 4. The Executive Director will be responsible for ensuring that the above corrections are completed and monitored.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080.

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

Based on interview and record review, it was determined the facility failed to instruct residents within 24 hours of admission and 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 02/10/26, the facility fire and life safety records were reviewed. The facility lacked documented evidence residents were instructed within 24 hours of admission and re-instructed, at least annually, on general safety procedures, evacuation methods, and responsibilities. In an interview on 02/10/26 at 10:29 am, Staff 1 (ED) confirmed the facility did not have documentation of a system for instructing residents of fire and life safety procedures at move-in or annually. The need to ensure that residents received instruction in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area within 24 hours of admission, and were re-instructed at least annually, was reviewed with Staff 1, Staff 2 (Wellness Director/RN) and Staff 3 (RCC) on 02/12/26 at 11:14 am. They acknowledged the findings.

The following actions will be taken to correct the violation: a. All current residents will receive training on the facility's Fire and Life Safety Policies in March 2026 during the Town Hall Meeting and individually in small groups for those who are not in attendance. 2. All newly admitted residents will receive training on the facility's Fire and Life Safety Policies within 24 hours of admission - this task will be added on the new resident checklist for the Marketing Director, to complete during the admission process. The Maintenance Manager, or designee, will complete the annual training for fire and life safety procedures with all residents once a year - presently scheduled on January 31st through the TELS system. Residents who are unable to attend the annual training will be provided the information for fire and life safety procedures one-on-one. The Maintenance Manager will keep a record of annual trainings provided for each resident and when they were completed in the Fire and Life Safety Binder. 3. The system to complete annual trainings and provide proper documentation of fire and life safety policies and procedures to all residents within 24 hours of admission and annually will be reviewed once a month during the monthly Management Meetings. 4. The Executive Director will be responsible for ensuring that the above corrections are completed and monitored.

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

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-0000. Findings include, but are not limited to: On 08/06/25 from 11:10 am until 12:20 pm, observations of the facility's kitchen identified the following: a. Food spills, splatters, debris, dirt, and/or black matter was observed on or underneath the following: * Walls throughout the kitchen; * Interior and exterior of the cabinets in the dining service area; and * Interior of the microwave. b. Food Storage: multiple items in dry storage were opened and not dated. c. Food Service: alcohol wipes were not available to staff for sanitizing the probe thermometer after use. d. Cleaning and Repair * The Hobart mixer was not covered when not it use; * There was a build-up of ice along the black pipe on the right hand ceiling of the walk-in freezer; * There was a chip in the corner of the wall by the Hobart mixer; * There was a worn area on the exit door with exposed wood, rendering the surface uncleanable; and * There were two cracked ceiling light covers above the stove and one cracked ceiling light cover in the dry storage area. e. Infection Control and Cleanliness: * Beard restraints were not available for staff use; * Tables in the dining area were set with cutlery with food surface contact areas exposed to potential contamination; and * Tables in the dining area were set with drinking glasses not stored in an inverted position. The kitchen was toured, and the above areas were discussed with Staff 1 (ED) and Staff 2 (Culinary Services Director) on 08/06/25 at 12:20 pm. The findings were acknowledged.

PROVIDER'S PLAN OF CORRECTION 1. The following actions will be taken to correct the violations. a. Food spills, splatters, debris, dirt and /or black matter was observed on or underneath the following: -Walls throughout the kitchen; - Interior and exterior of the cabinets in the dining service area; - interior of the microwave. The Chef Manager and the dining staff will be cleaning all the surfaces identified and the microwave. b. Food storage: multiple items in the dry storage were open and not dated. Chef manager will retrain all kitchen staff with food handling with regards to food handling with regards to food labeling and food storage. c. Food Service: Alcohol wipes were not available to staff for sanitizing the probe thermometer after use. The Chef manager has ordered alcohol wipes used for sanitizing probe thermometers. d. Cleaning and Repair: - The Hobart mixer was not covered when not in use. Chef Manager covered the Hobart mixer with a plastic bag when not in used. - There was a chip in the corner of the wall by the Hobart mixer. Maintenance manager will repair the chipped wall. - There was a worn area on the exit door with exposed wood, rendering the surface uncleanable. The maintenance manager will repair and paint the exit door with exposed wood to be a cleanable/wipeable surface. - There were 2 cracked ceiling lights cover above the stove and once cracked ceiling light cover in the Dry storage area. The Maintenance manager replaced both cracked ceiling lights. e. Infection Control and cleanliness. - Beard restraints were not available for staff use. The Chef manager purchased beard nets for staff use. - Tables in the dining area were set with cutlery with food surface contact areas exposed to potential contamination. The Chef Manager will train servers on properly covering cutlery to prevent contamination and ensure compliance with infection control standards - Tables in the dining room area were set with drinking glasses not stored in an inverted position. The Chef manager will provide training to the servers on properly setting drinking glasses inverted to prevent contamination and ensure compliance with infection control standards. 2. How will the system be corrected so this violation will not happen again. a. Chef Manager updated the cleaning checklist, including daily, weekly, and monthly scheduled tasks, to ensure that sanitation and food is prepared and served in accordance with the Oregon Food Sanitation Rules. b. Chef Manager will do an in service of proper food handling - labeling and dating opened items. Chef manager to do twice a week audit to ensure food is dated appropriately. c. Chef Manager will include alcohol wipes for monthly orders. d. Chef Manager and Cooks will make sure to cover the appliances, Hobart mixer when not in use. Chef Manager and Maintenance Manager will complete a visual check of the kitchen for potential needs quarterly or as needed. 3. How often will the area needing correction evaluated? The systems to ensure that food is prepared and served in accordance with the Oregon Food Sanitation Rules including repairs, cleaning, proper safe food handling practices will be evaluated by the Executive Director monthly during the monthly Management meeting. 4. Who will be responsible to see that the corrections are completed/monitored? The Executive Director will be responsible for overseeing that the above systems are in place and continuously monitored.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

Based on observation and interview it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-0000. This is a repeat citation. Findings include, but are not limited to: On 10/21/25, from 10:15 am until 10:35 am, observations of the facility's kitchen identified the following: a. Food spills and splatters were observed on the walls surrounding the stove and on the walls throughout the kitchen; b. Food Storage: multiple items in dry storage were opened and not dated. The kitchen was toured, and the above areas were discussed with Staff 1 (ED) on 10/21/25 at 10:35 am. The findings were acknowledged.

1. The following actions has been taken to correct the violations: a. The chef (Kitchen Manager) and cook has cleaned the food spills and splatter walls surrounding the stove and on the walls throughout the kitchen. b. All food items opened will be labeled with the date opened. 2. How will the system be corrected so this violation will not happen again? a. Staff in-servicing regarding cleaning of kitchen surfaces and sanitation rules. Cleaning schedule created and posted with daily task sheets for the staff to maintain compliance. b. Inservice staff on dates for all food items opened and provide labels for containers. Signs are put up in the dry storage, fridge door, and prep areas to remind them that date food items if they are opened. 3. The Chef (kitchen manager) observes the kitchen for cleanliness daily. Task sheets and kitchen logs will be reviewed daily until compliance is met and then weekly. 4. The Chef and Executive Director will be responsible for overseeing that the above system is in place and continuously monitored.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation.

Based on observation, interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to: Refer to C240.

Refer to C240

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation.

Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. Findings include, but are not limited to: During the re-licensure survey, conducted 08/05/24 through 08/07/24, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the scope, severity, and number of citations. Refer to deficiencies in the report.

1. Markham House will employ a full-time, 40 hours a week, licensed RCF Administrator with experience and a successful history in leading a community-based care setting as an Executive Director. 2. The Executive Director, in addition to the business office manager, will have meetings and check-ins with the owner and provide updates in the resident care and services rendered by the facility. 3. Owner will evaluate the Executive Director's ability to provide administrative oversight during the bi-monthly check-ins with the Executive Director and the business office manager 4. The Executive Director is responsible for providing effective administrative oversight to the facility. The business office manager and the owner will be responsible for monitoring the successful administrative oversight in the facility.

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 08/05/24 at 10:15 am, the following areas were observed in the kitchen: * The ceiling vents and sprinklers had a layer of dust; * The floor underneath the dishwasher had an uneven surface, cracks and water damage; * The dishwasher digital thermometer indicated that the rinse cycle temperature reached between 150 F and 170 F, not 180 F as indicated on the dishwasher data plate. * Two staff did not restrain their hair. The findings were discussed with Staff 1 (Resident Care Manager) and Staff 2 (Chef) on 08/07/24. The findings were acknowledged.

1. The following actions will be taken to correct the violations: a. The ceiling vents and sprinklers covered with dust will be cleaned by the Maintenance manager. b. The floor underneath the dishwasher has an uneven surface, cracks and water damage. The uneven surface, cracks on flooring and water damaged will be repaired and fixed by an outside provider / maintenance manager. c. The dishwaher digital thermometer indicated rinse cycle temprature reached between 150 F and 170 F, not 180 F as indicated on the diswasher data plate. The digital thermometer has been fixed and is consistently reaching 180 F temprature rinse cycle. d. Two staff did not restrain their hair. Dietary staff will be provided an in-service training regarding safe food handling and infection control procedure, including wearing aprons and tying/restratining hair during kitchen service. Signs/ reminders will be placed regarding restraining/ tying  their hair while in service. 2. How will the system be corrected so this violation will not happen again? a. Chef Manager and POD will complete a visual check of the kitchen for potential needs for repair quarterly and as needed. POD will clean the clean the vents and sprinkler quarterly and as needed. Chef manager will be checking the dishwasher temprature monthly to ensure that the thermometer is acccurate. b.Every dietary employees will continue to receive biannual trainings of safe food handling practices. For every new employee, dining staff members will receive safe food handling training as part of pre-service requirements, in addition to the bi-annual scheduled trainings. 3.The systems to ensure  that food is prepared and served in accordance with the Oregon Food Sanitation Rules including cleaning, repairs, proper safe food handling practices will be evaluated by Executive Director monthly during monthly Management Meeting. 4. The Excutive Director will be responsible for overseeing that the above systems are in place and continously monitored.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained and food was stored in accordance with the Food Sanitation Rules OARs 333-150-0000. This is a repeat citation. Findings include, but are not limited to: On 12/17/24, the following areas were observed in the kitchen: * The flooring below the dish machine was damaged and pulling up. * The hand washing sink faucet was damaged and basin was soiled and had debris. * There were multiple undated, unlabeled, or uncovered food items in the walk in refrigerator and the deli-refrigerator. * Butter, a potentially hazard food, was left un-refrigerated on the dining room tables. The areas in need of repair and the food storage concerns were discussed with Staff 2 (Culinary Services Director) and Staff 18 (ED). They acknowledged the findings.

1. The following actions will be taken to correct the violations. a. The flooring underneath the dish machine was damaged and pulling up. The flooring underneath the dish machine will be replaced/repaired by an outside contractor. b. The handwashing sink faucet was damaged and basin was soiled and had debris. Maintenance Manager will fix the faucet, clean the sink and put a " hand washing sink"  sign only. c.There were multiple undated, unlabeled, or uncovered food items in the walk-in refrigerator & the deli-refrigerator. Chef manager will re-train all kitchen staff with safe food  handling with regards to food labeling and food storage. d. Butter, a potentially hazard food, was left un-refrigerated on the dining room tables. Chef manager has instructed kitchen staff to refrigirate  the butter and  serve the butter as needed/ requested by residents and not be left out in the dining room. 2. How will the system be corrected so this violation will not happen again? a. Chef Manager and POD will complete a visual check of the kitchen for potential needs for repair quarterly and as needed. b.  Every dietary employees will continue to receive biannual trainings of safe food handling practices. For every new employee, dining staff members will receive safe food handling training as part of pre-service requirements, in addition to the bi-annual scheduled trainings. 3. How often will the area needing correction be evaluated? The systems to ensure that food is prepared and served in accordance with the Oregon Food Sanitation Rules including cleaning, repairs, proper safe food handling practices will be evaluated by Executive Director monthly during monthly Management Meeting. 4. Who will be responsible to see that the corrections are completed/ monitored? The Excutive Director will be responsible for overseeing that the above systems are in place and continously monitored.

2. Resident 1 moved into the facility in 07/2024 with diagnoses including type II diabetes without complication. The resident's 07/02/24 service plan was reviewed, observations were made, and interviews with caregivers were conducted during the survey. a. The 07/02/24 service plan, which was available to staff, was not updated within 30-days of move-in to reflect changes in skin and ADLs status. b. In addition, Resident 1's service plan was not reflective, did not provide clear direction to staff and/or was not implemented in the following areas: * Customary routines; * Oral health status; * Personal hygiene status; * Repositioning/bed mobility status; * Use of side rails; * Ability to use call system; * Bowel management; * Transfer status including using mechanical lift; and * Pain status. The need to ensure service plans were reflective of the resident's needs, provided clear direction to staff and implemented was discussed with Staff 1 (Resident Care Manager) and Witness 1 (Consultant RN) on 08/06/24 and 08/07/24. The findings were acknowledged.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were updated at 30-days after move-in, at least quarterly, reflective of residents' needs, were readily available to staff, and provided clear direction regarding the delivery of services for 2 of 4 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 11/2021 with diagnoses including cognitive impairment and dementia. Observations of the resident, interviews with staff, and review of the resident's record, were completed during the survey. a. The current service plan available to staff, dated 02/05/24, had not been updated quarterly, was not reflective of the resident's current care needs or did not provide clear direction to staff in the following area: * weight change status. b. Review of the resident's record noted a significant change of condition on 06/24/24 related to weight loss. There was no documented evidence the service plan had been reviewed and updated as needed. The need to ensure resident service plans were updated at least quarterly, available to staff, reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Resident Care Manager) and Staff 4 (Business Office Manager) on 08/07/24. They acknowledged the findings.

1.) The following actions will be taken to correct the violation for each resident: a. Resident 3's service plan, dated 2/5/24 has been reviewed by the Registered Nurse and the service plan updated to reflect the weight change status. Resident 3's service plan will be updated to include clear instructions to care staff on how to assist resident with her current care needs, including any interventions with a significant change of condition like a weight change. Updates to the resident's service plan and directions for staff on how to provide and deliver services will be discussed at the upcoming All-Staff Meeting amd Health & Wellness Meeting to allow for a clear understanding of responsibilities and for questions and concerns to be discussed. b. Resident 1's service plan dated 7/2/24 has been reviewed and updated to reflect resident's current care needs, the identified missing items, and resident preferences. Additionally, Resident 1's service plan will be updated to include clear instruction to care staff on how to assist resident with his current care needs. Updates to the resident's service plan and directions for staff on how to provide and deliver services will be discussed at the upcoming All-Staff Meeting & Health and Wellness Meeting to allow for a clear understanding of responsibilities and for questions and concerns to be discussed. 2. To prevent reoccurence, all service plans will be audited weekly by the RCC or designee to reflect the resident's current care and and provide clear direction to the staff. RCC or designee will do a weekly audit on the service plan binder to ensure the most current service plan is availabe to the staff and that stafff has read and signed the service plans that have been reviewed. A portion of all staff meeting will be set aside to discuss any concerns and questions about how to provide care services to any resident to ensure understanding of staff responsibilities. 3.The systems to ensure the thorough completion of quarterly service plans, including clear directions to staff, will be evaluated by Wellness Manager,Licensed  Nurse and the Excutive Director monthly during Monthly Wellness Meetings. 4. The Executive Director and the Health and Wellness Manager will be responsible for overseeing that the above systems are in place and continously monitored.

Based on observation, interview, and record review, it was determined the facility failed to ensure changes of condition had determined and documented resident specific actions or interventions, were communicated to staff, and/or were monitored weekly through resolution for 3 of 4 sampled residents (#s 1, 2 and 3) who experienced changes of condition. Resident 1 developed unstageable pressure sores. Findings include, but are not limited to: Resident 1 moved into the facility in 07/2024 with diagnoses including, type II diabetes mellitus without complications, aftercare following surgical amputation and acquired absence of left foot. a. During the acuity interview on 08/05/24, the resident was identified to have a pressure sore in the coccyx area and received hospice services. The 07/01/24 initial evaluation indicated "no skin concerns needing treatment or monitoring." During an interview on 08/06/24, Witness 1 (RN Consultant) reported the resident admitted with a pressure sore on the coccyx area. The resident's current service plan, updated 07/02/24, hospice visit notes, dated 07/09/24 through 07/31/24, progress notes dated 07/03/24 through 08/04/24 and "Skin Issues (minor) LN[licensed nurse] Tracking and Weekly Progress note" were reviewed. Staff were interviewed. Staff documented the following in the resident's progress notes: * 07/05/24 - "Barrier cream applied to 1 cm x 2 cm redness to coccyx."; and * 07/10/24 - " ...another bed sore starting." The skin issues tracking and weekly progress note showed the following: * 07/03/24 - 3 cm x 1 cm. stage II; * 07/10/24 - hospice changed dressing; and * 07/17/24 - dressing intact. No complaint of pain. There was no documented evidence the facility evaluated the resident condition, document the changes and updated the service plan when the facility identified the pressure sores. Additionally, there was no documented evidence the facility monitored the pressure sores at least weekly. Further review of the skin tracking and weekly progress notes showed the following: * 07/24/24 - worsening wound bed. Unstageable; and * 07/31/24 - no changes to wound bed. Hospice visit notes showed the following: * 07/24/24 - "Worsening coccyx wound stage I, now unstageable." During the survey, between 08/05/24 and 08/07/24, Resident 1 was observed in bed at all times and required staff assistance with bed mobility. There was no documented evidence the facility completed a full evaluation to determine the resident's condition, monitored the resident's change in skin condition, or re-evaluated the resident when the new pressure sore was identified. In addition, there was no documented evidence the facility developed interventions to ensure the pressure sore did not get worse. The facility's failure to evaluate the resident's skin condition and to determine actions or interventions, document and communicate the actions or interventions with staff on all shifts, and to monitor interventions for effectiveness created a risk of harm to the resident as s/he developed unstageable pressure sores. b. Resident 1's progress note, dated 07/03/24 through 08/04/24 and the MAR, dated 07/0124 through 08/06/24 showed the following: * 07/03/24 - "on alert for new move in."; and * 07/23/24 - on antibiotic for cellulitis. There was no documented evidence the changes of condition in skin and initiation of antibiotic were monitored through resolution. The need to ensure changes in residents' skin was evaluated, actions or interventions were determined, documented, communicated to staff on all shifts, and implemented, ensure interventions were monitored for effectiveness and the changes of condition were monitored through resolution was discussed with Staff 1 (RCM) and Staff 4 (Business Office Manager) on 08/07/24. They acknowledged the findings. 3. Resident 2 moved into the facility in 07/2024 with diagnoses including dementia and syncope. The resident's current service plan dated 07/09/24, and progress notes dated 07/16/24 through 08/05/24 were reviewed.   The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts and progress noted at least weekly through resolution: * 07/20/24: Return from the hospital due to elevated blood pressure. The need to ensure resident-specific actions or interventions for short term changes of condition were determined, documented, communicated to staff on each shift and the changes of condition were monitored, at least weekly, through resolution was discussed with Staff 1 (Resident Care Manager). She acknowledged the findings. 2. Resident 3 was admitted to the facility in 11/2021 with diagnoses which included cognitive impairment and dementia. Observations of the resident, interviews with staff and Resident 3, and review of the resident's medical chart were conducted during the survey. Resident 3's record revealed the following weights: *05/10/24: 152.4 lbs.; *06/24/24: 139.6 lbs.; *07/05/24: 139.6 lbs.; *08/03/24: 137.2 lbs.; and *08/05/24: 135.2 lbs. Between 05/10/24 and 06/24/24 Resident 3 lost 12.8 lbs or 8.4% of his/her body weight representing a significant change of condition. An RN assessment was completed for Resident 3's weight loss on 06/24/24, however there was no documented evidence actions/interventions were developed, communicated to staff nor was the change monitored weekly through resolution. At the time of the survey, 08/05/24 the resident weighed 135.2 lbs. On 08/05/24 at 2:45 pm, in an interview with the resident, s/he stated they ate breakfast and lunch in their room. S/he also stated the food at the facility was good. It was observed the resident had a kitchenette in unit including a refrigerator and microwave to contain and prepare snacks. On 08/05/24 at 2:30 pm, in an interview with Staff 7 (CG/MT) and Staff 12 (CG), they stated Resident 3 was able to eat and choose meals independently. The need to ensure the facility had a process for determining what actions or interventions were needed for a resident and providing written instructions to staff following a change of condition was reviewed with Staff 1 (Resident Care Manager) and Staff 4 (Business Office Manager) on 08/07/24. They acknowledged the findings.

1. The following actions will be taken to correct the violation for each resident: a. Resident 1's wound has been re-assessed by a Registered Nurse and been addressed by a hospice physician. His most current wound care orders, along with additional recommendations will be added to the Treatment Administration Record on EMAR. Registered Nurse will continue to evaluate, monitor, and document on Resident 1's wound progression and effectiveness of current interventions and ordered treatments weekly until resolved or at new baseline. The  Registered nurse will provide education to all care staff members on what signs and symptoms to monitor for, when to alert a licensed nurse of concerns, how to alert a licensed nurse of concerns, and when the wound needs urgent medical attention. Clear and specific directions will be provided to staff via written documentation in EMAR and in the resident's service plan. Registered Nurse will continue to monitor for any potential signs that the wound has progressed to a significant change of condition. b. Resident 3's weights were reasseed and  service plan was updated to include weekly weights, interventions such as offering snacks in between meals and offering a supplemental shake. Clear and specific directions will be provided to staff via written documentation in EMAR ans in the resident's service plan.  Registered Nurse will monitor progress weekly until weight has returned to baseline or until a new baseline is determined.   c. Resident 2's service plan was re-assesed by the Registered Nurse for short-term changes due to elevated blood pressure and the findings were communicated with the resident's provider. Current orders were entered in MAR and interventions like monitoring of BP. Registered Nurse will provide training to care staff members on what signs & symptoms to monitor for and when to alert Health and Wellness Manager or Licensed Nurse.  Clear and specific dierections will be provided to care staff via written documentation in EMAR and in the resident's service plan. Health and Wellness Manager will monitor weekly until resolved or unless the resident's condition changes significantly resulting in the Registered Nurse's involvement in the change of condition. 2.A visual list of residents with skin issues, wounds, falls, changes of condition, and re-admission from hospitalization will be placed on a communication board in the Health & Wellness Office, along with the most recent date of evaluation. This list of residents will be discussed during weekly clinical meetings with the rhe licensed nurse, RCC, Health & Wellness Manager , and the Executive Director. Any updates to resident-specific interventions will be communicated to care staff by providing clear instructions via the service plan. Weekly clinical meetings will include reviewing TSPs, outside provider notes, skin sheets, progress notes, and 24-hour alert logs to identify any changes of condition or wounds that have not yet been addressed by the licensed nurse. 3. The effectiveness of the visual list of residents via a communication board and the discussions of changes of conditions during weekly clinical meetings will be reviewed by the Licensed Nurse, Health & Wellness Manager and the Executive Director monthly during monthly Wellness Management meetings. 4. The Executive Director and th Health and Wellness Manager will be resposible for ensuring that the correction are completed and monitored.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN completed an assessment that documented findings, resident status, and interventions made as a result of the assessment for 1 of 4 sampled residents (# 1), who experienced significant changes of condition in skin. Findings include, but are not limited to: Resident 1 moved into the facility in 07/2024 with diagnoses including, type II diabetes mellitus without complications, aftercare following surgical amputation and acquired absence of left foot. During the acuity interview on 08/05/24, the resident was identified to have a pressure sore on the coccyx area. During the interview on 08/06/24, Witness 1 (RN Consultant) reported the resident admitted with the pressure sore on the coccyx area. The resident's current service plan, updated 07/02/24, was reviewed. There was no specific interventions for the pressure sore provided to staff to follow. Hospice visit notes, dated 07/09/24 through 07/31/24, progress notes dated 07/03/24 through 08/04/24 and "Skin Issues (minor) LN [Licensed Nurse] Tracking and Weekly Progress note" were reviewed. Staff were interviewed. Staff documented the following in the resident's progress notes: * 07/10/24 - " ...another bed sore starting." The skin issues tracking and weekly progress note showed the following: * 07/10/24 - hospice changed dressing; * 07/17/24 - dressing intact. No complaint of pain; * 07/24/24 - worsening wound bed. Unstageable; and * 07/31/24 - no changes to wound bed. The unstageable pressure sore represented a significant change of condition. There was no documented evidence the facility completed assessment for the significant change of condition in skin, document the resident status, and interventions made as a result of the assessment. On 08/07/24, Witness 1 via phone interview, reported that she was not able to answer if there was an RN assessment or not when she was aware of the unstageable pressure sore. On 08/07/24, the need to ensure the facility RN completed an assessment for the significant change of condition was discussed with Staff 1 (Resident Care Manager) and Staff 4 (Business Office Manager). They acknowledged the findings.

1. The following actions will be taken to correct the violation for each resident: Resident 1's service plan will be updated to include a previous significant change of condition in skin, intervention, current care needs, and resident preferences, and clear instructions to care staff and how to care for and monitor wound. Care staff will be provided education on what may constitute as a significant change of condition and when/how to alert the licensed nurse of urgent concerns during the during the upcoming All Staff Meeting and Health & Wellness Meeting. 2. A visual list of residents with skin issues, wounds, falls, changes of condition, and re-admission from hospitalization will be placed on a communication board in the Health & Wellness Office, along with the most recent date of evaluation. This list of residents will be discussed during weekly clinical meetings with the the licensed nurse, RCC, Wellness Manager , and Executive Director. Any updates to resident-specific interventions will be communicated to care staff by providing clear instructions via the service plan. Weekly clinical meetings will include reviewing TSPs, outside provider notes, skin sheets, progress notes, and 24-hour alert logs to identify any changes of condition or wounds that have not yet been addressed by the licensed nurse. 3. The effectiveness of the visual list of residents via a communication board and the discussions of changes of conditions during weekly clinical meetings will be reviewed by the Licensed Nurse, Wellness Manager and the Executive Director monthly during monthly Wellness Management meetings. 4. The Executive Director and the Health & Wellness Manager will be resposible for ensuring that the correction are completed and monitored.

2. Resident 1 moved into the facility in 07/2024 with diagnoses including type II diabetes without complication, aftercare following surgical amputation and acquired absence of left foot. During the acuity interview on 08/05/24, the resident was identified to receive outside hospice services. The resident's current service plan, updated 07/02/24, hospice visit notes, dated 07/09/24 through 07/31/24 and progress notes dated 07/03/24 through 08/04/24 were reviewed. Hospice visits showed the following: * 07/24/24 - Do not use plastic or vinyl sheets; and * 07/31/24 - Reposition the resident every two hours while awake and every four hours at night. In the review of the resident's clinical record, there was no documented evidence staff were informed of the new instructions and the service plan was updated for the recommendation. The need to ensure staff were informed of new instructions and the service plan was updated as necessary after on-site health services were provided was discussed on 08/07/24 with Staff 1 (Resident Care Manager) and Witness 1 (RN Consultant) on 08/06/24 and Staff 1 and Staff 4 (Business Office Manager) on 08/07/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care, the facility failed to ensure staff were informed of new interventions, and the service plan was adjusted if necessary for 2 of 2 sampled residents (#s 1 and 2) who received outside services. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 07/2024 with diagnoses including dementia and syncope. Progress notes, outside provider notes dated 07/31/24, and the service plan dated 07/09/24 were reviewed. There was no documented evidence staff were informed of the new instructions and the service plan was updated for the following recommendation: * 07/31/24-HH OT noted: The resident needs positional changes every 1-2 hours with brief checked for moisture as s/he is at a higher risk for pressure injury due to immobility. Please check brief every 1-2 hours. The need to ensure staff were informed of new instructions and the service plan was updated as necessary after on-site health services were provided was discussed on 08/07/24 with Staff 1 (Resident Care Manager). She acknowledged the findings.

1. The following actions will be taken to correct the violation for each resident: a. Resident 2's Home Health Occupational Therapy  notes will be requested for all previous visits ocucured including potential orders for and instructions for repositioning and frequent brief/ toileting assists to prevent pressure sores. The licensed nurse will review all notes, orders, and instructions. The Heaslth & Wellness Manager or designee will document outside provider service care coordination note via a progress note on EMAR. The licensed nurse will input treatment instructions on EMAR and the resident's service plan for clear instructions for care staff. New information from Home Health notes for Resident 1 will be discussed during end of shift change report, the weekly clinical meeting and at the next monthly Health & Wellness Meeting. b. Resident 1's Hospice notes will be requested for all visits with Resident 1 for wound care, including any orders for wound care and recommendations. The licensed nurse will review all notes, orders, and instructions. The Health & Wellness or designee will document outside provider service care coordination note via a progress note on EMAR. The licensed nurse will input treatment instructions on EMAR and the resident's service plan for wound care. New information from Hospice notes for Resident 1 will be discussed during end of shift change report, at the weekly clinical meeting and at the next monthly Health & Wellness Meeting. 2 A visual list of residents receiving services from Home Health/ Hospice  providers will be placed on a communication board in the Health & Wellness Office, along with the reason for visits, date of latest visit and potential date of discharge, as appropriate. Outside provider notes will be documented on as a progress note in EMAR by the medtech. The Resident Care Coordinator, or Wellness Director, will request outside provider care plans and progress notes biweekly. The licensed nurse will review the obtained outside provider care plans and progress notes, in addition to documenting findings as a progress note on EMAR and adding treatment orders on EMAR as needed. The licensed nurse will update the resident's service plan and will provide education and clear instructions to care staff on what services the resident needs, how to assist with such services, how to and when to monitor for adverse side effects, and how to and when to alert a licensed nurse of concerns. This list of residents receiving Hospice/ Home Health Services/ Outside Providers will be discussed during weekly clinical meetings with the licensed nurse, RCC, Wellness Manager and Executive Director. Weekly clinical meetings will include reviewing TSPs, outside provider notes, skin sheets, progress notes, and 24-hour alert logs to identify any needs for Hospice /Home Health Service or any current Hospice/Home Health Services that have not yet been addressed by the licensed nurse. 3. The effectiveness of the visual list of residents receiving Home Health/ Hospice Services via a communication board and the discussions held during weekly clinical meetings will be reviewed by the Health & Wellness Manager and the Executive Director monthly during monthly Wellness Management meetings. 4. The Health & Wellness Manager and the Executive Director will be responsible for ensuring that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care, the facility failed to ensure staff were informed of new interventions, and the service plan was adjusted if necessary for 1 of 1 sampled resident (# 6) who received outside services. This is a repeat citation. Findings include, but are not limited to: Resident 6 moved into the facility in 08/2024 with diagnoses including aftercare following joint replacement surgery. Progress notes from 10/02/24 through 12/11/24 and the 11/28/24 service plan were reviewed. There was no documented evidence staff were informed of the new instructions and the service plan was updated for the following recommendation: * 11/04/24: New instructions from HHPT to change the resident's shirt while seated at the edge of the bed; * 11/06/24: Continue encouraging the resident to sit at the edge of the bed; and * 11/19/24: New instructions from HHPT to encourage the resident sitting at the edge of the bed. The need to ensure staff were informed of new instructions and the service plan was updated as necessary after on-site health services were provided was discussed on 12/17/24 with Staff 18 (ED) and Staff 19 (RN). They acknowledged the findings.

1. The following actions will be taken to correct the violation for Resident: Resident 6's Home Health Physical Therapy notes will be requested for all previous visits occurred including all potential orders for instructions for encouraging resident to sit on the edge of the bed. The Registered Nurse will review all notes, orders and instructions. The RCC or Designee will document outside provider service care coordination note via a progress notes on EMAR. The RN will input treatment instruction on EMAR, Temporary Service Plan and the resident service plan for clear instructions for the care staff. New information from Home Health notes for Resident 6 will be discussed during end of shift report, the weekly clinical meeting and the next montly Health and Wellness Meeting. 2.How is the system be corrected so the violation will not happen again? A visual list of residents receiving services from Home Health/ Hospice providers will be placed on a communication board in the Health & Wellness Office, along with the reason for visits, date of latest visit and potential date of discharge, as appropriate. Outside provider notes will be documented on as a progress note in EMAR by the medtech. The Resident Care Coordinator, or Wellness Director, will request outside provider care plans and progress notes biweekly. The licensed nurse will review the obtained outside provider care plans and progress notes, in addition to documenting findings as a progress note on EMAR and adding treatment orders on EMAR as needed. The licensed nurse will update the resident's service plan and will provide education and clear instructions to care staff on what services the resident needs, howto assist with such services, how to and when to monitor for adverse side effects, and how to and when to alert a licensed nurse of concerns. This list of residents receiving Hospice/ Home Health Services/ Outside Providers will be discussed during weekly clinical meetings with the licensed nurse, RCC, Wellness Manager and Executive Director. Weekly clinical meetings will include reviewing TSPs, outside provider notes, skin sheets, progress notes, and 24-hour alert logs to identify any needs for Hospice /Home Health Service or any current Hospice/Home Health Services that have not yet been addressed  by the licensed nurse. 3. How often will the area needing correction be evaluated? The effectiveness of the visual list of residents receiving Home Health/ Hospice Services via a communication board and the discussions held during weekly clinical meetings will be reviewed by the Health & Wellness Managerand the Executive Director monthly during monthly Wellness Management meetings. 4. Who will be responsible to see that the corrections are completed/monitored? The Health & Wellness Manager and the Executive Director will be responsible for ensuring that the corrections are completed and monitored.

2. Resident 1 moved into the facility in 07/2024 with diagnoses including type II diabetes without complication, aftercare following surgical amputation and acquired absence of left foot. Review of Resident 1's current physician orders and MARs from 07/01/24 through 08/06/24 identified the following: * The resident was prescribed Keflex 250 mg [antibiotic] three times a day for 5 days for suspected cellulitis, however, the MAR indicated the resident received four extra doses of the antibiotic. * The resident was prescribed wound care orders to coccyx and Polyethylene powder once a day for constipation; however, the wound care and the Polyethylene powder orders were not transcribed on the MAR for staff to follow. The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Resident Care Manager) and Staff 4 (Business Office Manager) on 08/07/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 2 of 4 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to : 1. Resident 2 was admitted to the facility in 07/2024 with diagnoses including dementia and syncope. Resident 2's current physician orders and MAR, dated 07/01/24 through 07/31/24, were reviewed and revealed the following: The resident had physician orders dated 07/26/24 for the following: * Monitor blood pressure in the morning before giving meds; if systolic blood pressure is less than 100, let home health know. On 08/06/24 at 9:50 am, the surveyor and Staff 6 (MT) reviewed the electronic MAR and physician orders. Staff 6 confirmed the order to monitor blood pressure in the morning before giving meds; if systolic blood pressure is less than 100, let home health know, was not transcribed on the MAR for staff to follow. The need to ensure all physician orders were carried out as prescribed was discussed with Staff 1 (Resident Care Manager) on 08/07/24. She acknowledged the findings.

1.) The following actions will be taken to correct the violation for each resident: a. Resident 2's current medication list will be reviewed by the licensed nurse to ensure that all medications and treatments being administered has a signed physician's order and that all orders are accurately reflected on EMAR, including parameters. Once the medication list has been reviewed, a most recent up-to-date signed physician's order will be requested from the provider. b. Resident 1's current orders for medicaiton and Hospice orders for wound care will be reviewed by the licensed nurse to ensure that all medications and treatments being administered has a signed physician's order and that all orders are accurately reflected on EMAR. Once the medication list has been reviewed, a most recent up-to-date signed physician's order will be requested from the provider. 2. All med-techs for the community will receive a re-training conducted by Registered Nurse regarding policies and procedures, including requirement for signed physician's orders with all administered medications/treatments and importance of accurate medication administration as prescribed. The RCC, or Health & Wellness Manager, will review and audit the "three check system" in the medroom and make changes as needed to continue to make sure that all orders have been processed appropriately. The RCC, or Health & Wellness Director, will immediately alert the licensed nurse of any discrepancies. 3.) The audit and review of physician orders will be reviewed by the Wellness Manager and the Executive Director monthly during monthly Wellness Management meetings. 4.) The Wellness Manager and the Executive Director will be responsible for ensuring that the corrections are completed and monitored.

2. Resident 1 was admitted to the facility in 2018 with diagnoses including diabetes, aftercare following surgical amputation and acquired absence of left foot. a. Resident 1 had a physician order to administer Senna Plus one tablet once a day as needed and Bisacodyl 10 mg suppository once a day as needed for constipation. Resident 1's 07/01/24 through 08/06/24 MAR showed there were no resident-specific parameters including when to administer the PRN medication. b. Resident 1 had a physician order to administer Ativan 0.5 mg every four hours as needed for agitation/anxiety. Resident 1's 07/01/24 through 08/06/24 MAR showed there were no resident-specific instructions on how the resident expressed agitation and anxiety to determine when staff were to administer the PRN medication. The medication was administered three occasions (07/05/24, 07/10/24 and 07/13/24) during the review period. The need to ensure medications had resident-specific parameters for PRN medications and clear instructions for unlicensed staff was reviewed with Staff 1 (Resident Care Manager) and Staff 4 (Business Office Manager) on 08/07/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs  had resident-specific parameters for PRN medications and clear instructions to staff for 2 of 4 sampled residents (#s 1 and 3) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 3's 07/01/24 through 07/13/24 MAR was reviewed and revealed the following: Resident 3's MAR revealed multiple PRN medications that lacked resident-specific parameters and clear instructions to staff. * Acetaminophen 325 Mg Tabs (for fever, pain or headache) 1 - 2 tabs as PRN; and * Acetaminophen 500 Mg Caplet (for pain or fever) every eight hours PRN.   In an interview with Staff 1 (Resident Care Manager) at 11:00 am on 08/07/24, she acknowledged the lack of parameters and instruction for Resident 3's use of PRN Acetaminophen. The need to ensure PRN medications had resident-specific parameters and clear instructions to staff was reviewed with Staff 1 and Staff 4 (Business Office Manager) on 08/07/24. Staff acknowledged the finding.

1.) The following actions will be taken to correct the violation for each resident: a. Resident 3's current PRN orders for pain will be reviewed by the Registerd Nurse (RN). The RN will add clear parameters to provide clear and direct instructions for unlicesned staff as to when to, in what order, and what symptoms to administer each medication for pain as needed. b.1 Resident 1's current PRN orders for bowel care will be reviewed by the Registered Nurse. The RN will add clear parameters to provide instructions to unlicensed staff when to administer each medicaiton for bowel care, in addition to how long to wait in between doses and when a dose is considered to be ineffective requiring another dose or a different bowel care PRN medication. b.2 Resident 1's current PRN orders for Ativan for  agitation/anxiety will be reviewed by the Registed  nurse. The RN will provide clear & specific instructions on how resident expresses agitation and axiety and when it is appropriate to offer PRN medications for these symptoms. 2.All med-techs for the community will receive a re-training conducted by Registered Nurse regarding policies and procedures, including importance of parameters and clear instructions on how to administer PRN medications and treatments that are ordered for the same diagnosis. The Registered nurse will review and audit the MAR/TAR and add clear parameters to multiple PRN orders for the same diagnosis. The registered nurse will add clear parameters to all PRN medications and treatments as prescribed if needed. The registered nurse will review all PRN orders and include parameters, if needed, prior to sending out the 90 day physician orders every quarter. 3.) The audit and review of PRN orders to include clear parameters to unlicensed staff will be reviewed by the Health & Wellness Manager and the Executive Director monthly during monthly Wellness Management meetings. 4.) The Health & Wellness Manager and the Executive Director will be responsible for ensuring that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure all pre-service orientation topics for 4 of 4 newly-hired staff (#s 6, 12, 15 and 17) and pre-service dementia training for 4 of 4 newly-hired staff (#s 6, 7, 10 and 12) had been completed prior to staff beginning their job duties and HCBS training for 1 of 4 long-term staff (# 9) had been completed. Findings include, but are not limited to: The facility's training records were reviewed on 08/06/24 and the following was identified: a. There was no documented evidence Staff 6 (MT), Staff 12 (CG), Staff 15 (Cook), and Staff 17 (Dietary Server), hired 05/14/24, 06/03/24, 06/19/24, and 07/08/24, respectively, completed the following pre-service orientation topics prior to beginning their job duties: * Resident rights and the values of community-based care; * Fire safety and emergency procedures; * Infectious disease prevention training; * Fire safety and emergency procedures; and * Approved HCBS course. b. There was no documented evidence Staff 6, 7, 10, and 12 completed the following pre-service dementia training courses prior to providing care to residents: * Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to behaviors, including, but not limited to, reducing use of antipsychotic medications; * Strategies for addressing social needs & engaging persons with dementia in meaningful activities; and * Specific aspects of dementia including pain, providing food/fluids, preventing wandering, and the use of a person-centered approach. c. There was no documented evidence Staff 9 (CG), hired 11/01/22, completed HCBS training by 03/31/24. The requirements for pre-service orientation and training for all employees was reviewed with Staff 1 (Resident Care Manager) and Staff 4 (Business Office Manager) on 08/07/24. They acknowledged the findings.

1.) The following actions will be taken to correct the violation: a. Staff #6, Staff #12, Staff #15 and #17 will have all required pre-service trainings completed before working with residents and continuing their job duties b. Staff #6, staff #7, staff #10 and Staff #12 will have required  pre-dementia training completed before  working with residents and continuing their job duties. c.Staff #9 will have required HCBS training completed before working with residents and continuing their job duties. 2.) Pre-service training for all current employees will be completed prior to beginning their job duties. For the newly-hired employees,all pre-service trainings including pre-service dementia (6hr training), pre-service infection disease (2hr), resident rights and values of CBC, abuse reporting requirements, HCBS training, Fire & Safety emergency procedure, and food handler's certification, will be required prior to being placed on the schedule and working with residents. The appropriate department head will be responsible for reviewing completed training certifications for newly-hired employees in their department prior to adding them to the schedule to provide direct care to residents. 3.) The system to ensure that all employees have completed all required pre-service trainings prior to working with residents will be evaluated monthly during the monthly Management Meetings. The Executive Director and BOM director will do a monthly audit of the pre-service training requirements to ensure compliance. 4.) The Executive Director will be responsible for ensuring that the above corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure all pre-service orientation topics for 4 of 4 newly-hired staff (#s 20, 21, 22 and 23) and pre-service dementia training for 2 of 4 newly-hired staff (#s 20 and 21) had been completed prior to staff beginning their job duties. This is a repeat citation. Findings include, but are not limited to: The facility's training records were reviewed on 12/17/24 and the following was identified: 1. There was no documented evidence Staff 20 (MT), hired 10/8/24, and Staff 21 (MT), hired 10/18/24 completed the following pre-service orientation topics prior to beginning their job duties: * Infectious disease prevention training; and * Pre-service dementia training. 2. There was no documented evidence Staff 22 (MT), hired 10/2/24, and Staff 23 (CG), hired 11/5/24, completed the following pre-service orientation topics prior to beginning their job duties: * Resident Rights and values of CBC care; * Abuse Reporting; and * Fire Safety and emergency procedures. The requirements for pre-service orientation and training for all employees was reviewed with Staff 18 (ED), Staff 4 (Business Office Manager), and Staff 8 (RCC) on 10/17/24. They acknowledged the findings.

1. The follwing actions will be taken to correct the violation: a. Staff #20 & staff 21 will have all required pre-service infectious disease prevention and pre-service training will be completed before working with residents and continuing their job duties. b. Staff 22 & staff 23 will have required pre-service orientation Resident Rights & Values of CBC Care, Abuse Reporting and Fire Safety & Emergency Procedure will be completed before working with residents and continuing their job duties. 2.Pre-service training for all current employees will be completed prior to beginning their job duties. For the newly-hired employees,all pre-service trainings including pre-service dementia (6hr training), pre-service infection disease (2hr), resident rights and values of CBC, abuse reporting requirements, HCBS training, Fire & Safety emergency procedure, Providing Inclusive Care: Training for Oregon Long-Term Care Facility Staff and food handler's certification, will be required prior to beginning their job duties. 3. The system to ensure all employees have completed  all required pre-service trainings prior to working with residents will be evaluated monthly during the monthly management meetings. The Executive Director and BOM Director will do a montly audit of pre-service training requirements to ensure compliance. 4.The Executive Director will be the responsible for ensuring the above corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure and document that direct care staff demonstrated knowledge and performance in all required areas within 30 days of hire for 4 of 4 newly-hired staff (#s 6, 7, 10 and 12). Findings include, but are not limited to: The facility's training records were reviewed on 08/06/24 and the following was identified: There was no documented evidence Staff 6 (MT), Staff 7 (CG), Staff 10 (CG) and Staff 12 (CG), hired 05/14/24, 05/10/24, 02/15/24, and 06/03/24, respectively, demonstrated knowledge and satisfactory performance in the following topics: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; and * Fire aid/abdominal thrust. The need to ensure the facility documented direct care staff demonstrated knowledge and performance in all required areas within 30 days of hire was discussed with Staff 1 (Resident Care Manager) and Staff 2 (Business Office Manager) on 08/06/24 and 08/07/24. They acknowledged the findings.

1.) The following actions will be taken to correct the violation: a. Staff #9, #7, #10, #12 will have all required 30-day trainings completed and have demonstrated satisfactory performance in their required job duties. 2.) All current employees will be required to complete all the 30-day training requirements immediately. For newly-hired employees, all 30-day training requirements will be completed prior to their 30th day of hire. The Business Office Manager (BOM) and the RCC will be monitoring the 30-day training checklist for each employee. Those who have been unable to complete the 30-day training checklist prior to their 30th day of hire will be taken off the schedule until all required trainings have been completed. 3.) The system to ensure that all employees have completed all required trainings prior to their 30th day of hire will be evaluated monthly during the monthly Management Meetings. The Executive Director and BOM director will do a monthly audit of the pre-service training requirements to ensure timely compliance. 4.) The Executive Director will be responsible for ensuring that the above corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure and document that direct care staff demonstrated knowledge and performance in all required areas within 30 days of hire for 4 of 4 newly-hired staff (#s 20, 21, 22 and 23). This is a repeat citation. Findings include, but are not limited to: The facility's training records were reviewed on 12/17/24 and the following was identified: There was no documented evidence Staff 20 (MT), hired 10/8/24, Staff 21 (MT), hired 10/8/24, Staff 22 (MT), hired 10/2/24, and Staff 23 (CG), hired 11/5/24, demonstrated knowledge and satisfactory performance in the following topics: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; and * Fire aid/abdominal thrust. Staff 20 (MT), Staff 21 (MT), and Staff 22 (MT), lacked evidence of demonstrating competence in medication pass. The need to ensure the staff had documented evidence of demonstrating competence in passing medications before working as a medication aide and passing medications was discussed with Staff 18 (ED) and Staff 8 (RCC). Staff 18 (ED) and Staff 8 (RCC) agreed the staff would not pass medications until they had demonstrated competence. The need to ensure the facility documented direct care staff demonstrated knowledge and performance in all required areas within 30 days of hire was discussed with Staff 18, Staff 4 (Business Office Manager), and Staff 8 on 12/17/24. They acknowledged the findings.

1. The follwing actions will be taken to correct the violation: a. Staff #20, 21, 22 and 23 will have all the required  30 day trainings completed and have demonstrated statisfactory performance in their required job duties. b. Staff 20 (MT), Staff 21 (MT), Staff 22 (MT) will have all required medication pass training and have a evidence of demonstration on medication competency pass reviewed and signed  by Health and Services Director (RN). 2. All current employees will be required to complete all the 30-day training requirements immediately. For newly-hired employees, all 30-day training requirements will be completed prior to their 30th day of hire. All Medication Aide will have required medication pass training and demonstrated mediction competecy pass signed off by the HSD/Nurse.   The Business Office Manager (BOM) and the RCC will be monitoring the ,medication pass competency for medicatiion aides and 30-day training checklist for each employee. Those who have been unable to complete the 30-day training checklist prior to their 30th day of hire will be taken off the schedule until all required trainings have been completed. 3.The system to ensure that all employees have completed all required trainings prior to their 30th day of hire will be evaluated monthly during the monthly Management Meetings. The Executive Director and BOM director will do a monthly audit of the pre-service training requirements to ensure timely  compliance. 4.) The Executive Director will be responsible for ensuring that the above corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to have documented evidence that 12 hours of annual in-service training, including six hours related to the care of the dementia resident, was completed for 2 of 4 long-term staff (#s 8 and 9) and completed infectious disease training for 2 of 2 non-direct long-term staff (#s 14 and 16) whose training records were reviewed. Findings include, but are not limited to: Facility staff training records were reviewed on 08/06/24 and revealed the following: a. Training records for Staff 8 (MT/CG), hired 12/14/21 and Staff 9 (CG), hired 11/01/22, did not have documented evidence of required annual in-service training, including six hours relating to the care of residents with dementia. b. Training records for Staff 14 (Cook), hired 12/06/03 and Staff 16 (Dietary Server), re-hired 07/2023, did not have documented evidence of annual required infectious disease training. The need to ensure staff completed the required annual in-service training, based on anniversary dates of hire and infectious disease training was discussed with Staff 1 (Resident Care Manager) and Staff 4 (Business Office Manager) on 08/07/24. They acknowledged the findings.

1.) The following actions will be taken to correct the violation: a. Staff #8 and #9 will have all required annual in-service trainings, including 6 hours of dementia-related training, completed per the agreed upon schedule and deadline with each staff member. b.Staff #14 and #16 will have all required annual infectious desease training, completed per the agreed upon schedule and deadline with each staff member. 2.) All current employees will be required to immediately complete all 12 hours of annual in-service training requirements, including 6 hours of dementia-related training. For newly hired employees, monthly in-services through Relias and through scheduled in-person trainings will be tracked and monitored by the BOM and the RCC monthly. The BOM/RCC, or designee, will review certificates of trainings once a month and will provide assistance through a plan of action for those employees who have not yet fulfilled the monthly training requirement. 3.) The system to ensure that all employees have completed all 12 hours of annual in-service trainings will be evaluated monthly by the BOM and the Executive Director  during the monthly Management Meetings. 4.) The Executive Director will be responsible for ensuring that the above corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to provide documentation that fire drills were being conducted every other month, all required components of fire drills were documented, and fire and life safety instruction was provided on alternate months to staff. Findings include, but are not limited to: 1. Review of fire drill records on 08/05/24, dated 07/02/24, showed the facility failed to document the following required components: * Escape routes used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; * Evacuation time-period needed; and * Number of occupants evacuated. 2. The facility failed to provide documented evidence that fire and life safety instruction was being provided to staff on alternating months from fire drills.   On 08/06/24, the need to ensure all required components of fire drills were documented, fire and life safety instruction was provided on alternate months to staff was discussed with Staff 3 (Maintenance Director). He acknowledged the findings.

1.) The following actions will be taken to correct the violation: a. The fire drill record form will be updated to include all required elements including escape route, problems encountered, comments, related to residents who are resisted or failed to participate in the drills; staff members on duty & participating, evidence of alternate routes used during the fire drill and number of occupants evacuated. b. Staff will be provided with fire and life safety instructions by September 2024. Documentation of these instructions and each staff  will be kept in the Fire and Life Safety binder. 2.) Fire drills will include the practice of relocating identified residents to safe points/horizontal exits. Fire drills will be documented on the updated Fire and Life Safety form that will include all required elements. The Maintenance Manager, or designee, will be responsible for properly completing and documenting fire drills as required every other month. Additionally, a schedule has been developed by the Maintenance Manager to provide instructions and documentation of fire and life safety trainings, including emergency disaster preparedness, earthquakes, flooding, active shooter, ice storms, and electric outages, provided for all staff on alternate months from fire drills. 3.) The system to provide proper documentation of all required elements during a fire drill and proper documentation of safety instructions provided to staff on alternate months from the fire drill will be reviewed once a month during the monthly Management Meetings. 4.) The Executive Director will be responsible in ensuring that the above corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure each resident was instructed within 24 hours of admission and re-instructed, at least annually, in 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: In an interview on 08/06/24 at 9:00 am with Staff 3 (Maintenance Director), he stated the facility was not providing or documenting annual instruction for residents 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. Resident fire life safety training records were reviewed on 08/07/24 at 11:00 am with Staff 1 (Resident Care Manager). Staff 1 stated going forward she would be completing fire life safety instruction with residents within 24 hours of admission. The requirements for fire life safety instruction for residents were reviewed with Staff 1 and Staff 4 (Business Office Manager) on 08/07/24. They acknowledged the findings.

1.) The following actions will be taken to correct the violation: a. All current residents will receive training on the facility's Fire and Life Safety Policies in September 2024 during the Town Hall Meeting and individually io in small groups for those who are not in attendance. 2.) All newly admitted residents will receive training on the facility's Fire and Life Safety Policies within 24 hours of admission - this task will be added on the new resident checklist for the RCC, or Wellness Director, to complete during the admission process. The Maintenance Manager, or designee, will complete the annual training for fire and life safety procedures with all residents once a year - presently scheduled on January 31st through the TELS system. Residents who are unable to attend the annual training will be provided the information for fire and life safety procedures one-on-one. The Maintenance Manager  will keep a record of annual tranings provided for each resident and when they were completed in the Fire and Life Safety Binder. 3.) The system to complete annual tranings and provide proper documentation of fire and life safety policies and procedures to all residents within 24 hours of admission and annually will be reviewed once a month during the monthly Management Meetings. 4.) The Executive Director will be responsible in ensuring that the above corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to maintain all exterior pathways in good repair, and to ensure all facility grounds were kept orderly and free of refuse. Findings include, but are not limited to: The exterior of the building was toured on 08/05/24. The following issues were noted: * Multiple sections of the concrete path that encircled the building had drop-offs from the surface of the path to the planting bed of greater than two inches. This represented a fall risk for residents; and * An area observed on the rear grounds which included a mixture of old medical equipment, furniture, and building materials. This area was not kept orderly and presented a potential safety hazard for residents. On 08/06/24 at 9:00 am the need to ensure all exterior areas were maintained in good repair was discussed with Staff 1 (Resident Care Manager) and Staff 3 (Maintenance Director). They acknowledged the findings.

1.) The following actions will be taken to correct the violation: a. Concrete path around the building that has drop-offs from the surface of the path to the planting bed of greater than 2 inches will be filled with barkdust or pebbles. b. The rear grounds which included a mixture of old medical equipment, furniture and building materials were disposed. This area will be kept orderly to prevent any potential safety hazard for residents. 2. Maintenance Manager will do a weekly walkthough outside the community to identify potential safety hazard or fall risks - such as rear grounds or drops offs from the conrete path. Identified risks will be communicated to the Executive Director immediately and addressed  and corrected in an an urgent matter.  Executive Director and Maintenance Manager will complete a walk-through inspection of the community once a month to ensure that the building is kept clean and organized. 3.The system to keep the outside area will be evaluated once a month during the monthly management meeting. 4. The Executive Director is responsible for ensuring that the above corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to maintain all interior surfaces in good repair. Findings include, but are not limited to: The interior of the building was toured on 08/05/24. The following areas needed repair: * The carpet transition next to the front to the first floor wing was frayed and tearing; * The carpet throughout the first and second floors had spots and stains, particularly in the first floor activity room, and outside rooms 213, 216 and 223; and * The settee on the second floor (across from room 202) had a stain on it. On 08/06/23 at 9:00 am, the areas in need of repair were reviewed with Staff 3 (Maintenance Director). He acknowledged the findings.

1.) The following actions will be taken to correct the violation: a. The carpet transition next to the front of 1st floor was frayed and tearing will repaired or replaced by the Manintenance Manager or a third=party provider. b. The carpeting throught the first floor activity room  and throughout the second floor, outside rooms 213,216, abd 233 will be professionally shampooed and cleaned to remove dark spots or stains. c. The settee on the 2nd floor across room 202 that had stain on it will be cleaned or replaced. 2.The Maintenance Manager will schedule carpet shampooing and cleaning of all hallway and activity area through TELS system. The Manaintenace Manager will be responsible for having identified carpets needing to be shampooed and cleaned as before dark spots or stains set in. Quarterly upholstery cleaning for all community benches and chairs will be scheduled through the TELS system for the Maintenance and Housekeeping department to complete as scheduled and as needed. 3.) Maintenance Manager will complete a weekly walk-through inside the community to identify potential needs to clean and repair areas. Executive Director and Maintenance Manger will complete a walk-through inspection of the community once a month to ensure that the building is kept clean and good repair. The system to keep the building in clean and good repair will be evaluated once a month during the monthly Management Meetings. 4.) The Executive Director is responsible for ensuring that the above corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. Findings include, but are not limited to: The facility was toured on 08/05/24. Resident unit windows on the second floor opened vertically, and windowsills were lower than 36 inches. The windows lacked a system which limited how much the window could be opened to prevent accidental falls. The lack of a mechanism to prevent accidental falls was discussed with Staff 3 (Maintenance Director) on 08/06/24 at 9:00 am. He acknowledged the findings.

1.) The following actions will be taken to correct the violation: The windows on the second floor lacked a system on how much a window could be opened to prevent accidental falls. Maintenance manager will install a locking device to all windows on the second floor to prevent accidental falls. 2. The mainatenace manager will schedule a walkthrough quarterly through TELS to all apartments to check the window locks if it still in place. All staff will be instructed on how to identify potential safety hazards,who, when, and how to report potential safety concerns during the monthly All Staff Meeting. Maintenance Manager to immediately make a plan to investigate and address if appropiate all identified safety concerns. 3. The system to keep the resident safe will be evaluated oncee a month during the monthly Management meeting. 4.) The Executive Director is responsible for ensuring that the above corrections are completed and monitored.

Based on observation, interview, and record review, it was determined the facility failed to ensure their change of ownership survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C240, C290, C370 and C372.

Please refer to C240, C290, C370, and C372 response.

The findings of the change of ownership survey, conducted 08/05/24 through 08/07/24, 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 OARs 411 Division 004 Home and Community Based Services Regulations. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first re-visit to the change of ownership survey of 08/07/2024, conducted 12/17/24, 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 OARs 411 Division 004 Home and Community Based Services Regulations. 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 re-visit to the re-licensure survey of 08/07/24, conducted on 02/27/25, 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 OARs 411 Division 004 Home and Community Based Services Regulations.

Based on interview and record review, conducted during a site visit on 09/01/23, it was confirmed the facility failed to ensure medication and treatment orders were carried out as prescribed for 1 of 1 sampled resident (# 1) whose MAR was reviewed. Findings include, but are not limited to: A review of Resident 1's progress notes, dated 01/2021, indicated on 01/12/21, Resident 1 was determined to no longer be safe to self-administer medications after an RN assessment and the physician was notified and requested prescriptions for Resident 1's medications. A second request was made the Resident 1's physician on 01/14/21. A review of Resident 1's  MAR, dated 01/2021, indicated facility had created a MAR to begin facility administration on 01/23/21 with several medications denoted as "self-administration". Two of eight orders were not administered between 01/23/21 and 01/28/23. There was no evidence to indicate that eight of eight orders were administered between 01/12/23 and 01/23/21. Progress notes, dated 01/26/21, indicated the Health and Wellness Director  "will talk with staff tomorrow about a plan"  in reference to facility administering Resident 1's medications. In an interview on 09/01/23, Staff 1 (Administrator) stated s/he was did not know who Resident 1 was and was unaware of any concerns with Resident 1. The facility failed to ensure physician orders were carried out as prescribed. The findings of the investigation were reviewed with and acknowledged by Staff 1 on 09/15/23. Verbal Plan of Correction There is a new management team in the building to make sure this doesn't happen again. The Health and Wellness Director makes sure there are no changes to residents medication status' until the facility has received physician orders then s/he will fax Omnicare to either add a resident if s/he is going from self-medicating to facility management or to remove a resident if going from facility managing to self-medicating, then the Health and Wellness Director will update the residents care plan, print it and have all of the med techs review the information followed by the caregivers.

Based on interview and record review, conducted during a site visit on 09/01/23 it was determined the facility failed to implement an acuity-based staffing tool (ABST)  for 2 of 3 sampled residents (#s 2 and 3). Findings include, but are not limited to: In an interview on 09/01/23, Staff 1 (Administrator) stated the facility uses ElderMark and there is a point value assigned that has a time allotted to it, and the facility currently staffs based on the number of residents and the point values for time. A review of the facility's ABST indicated the tool failed to include all of the 22 required ADL components for the 3 sampled residents to include; · If multiple staff are required to assist with transferring and completing tasks in previous question, how much additional time is needed. · Providing treatments (e.g., skin care, wound care, antibiotic treatment.) Resident 2 and 3s' ABST failed to address the following required ADL components: · Providing non-drug interventions for pain management. · Monitoring physical conditions or symptoms. · Providing additional care service, such as smoking assistance or pet care. Resident 3's ABST also failed to address the following required ADL component: · Ensuring non-drug interventions for behaviors. The facility failed to fully implement an acuity-based staffing tool that met regulations. The findings of this investigation were reviewed with and acknowledged by Staff 1 on 09/15/23.

The findings of the on-site investigation, conducted 09/01/2023 through 09/15/2023, 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.