Lakeland Senior Living

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents.

Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the immediate health, safety, or welfare of residents for 1 of 1 sampled resident (# 4) who smoked and used oxygen. Resident 4 smoked while wearing an oxygen cannula. This placed residents at risk and constituted an immediate threat to residents’ health and safety. Findings include, but are not limited to: Resident 4 was admitted to the facility in 09/2025 with diagnoses including chronic obstructive pulmonary disease. ? Resident 4's current service plan and evaluation, dated 03/05/26, noted the resident smoked, used oxygen as needed, and was alert and oriented. There was no indication of whether the resident was able or willing to remove his/her oxygen prior to smoking or what the resident did with his/her oxygen tank while smoking. During an interview on 06/02/26 at 2:36 pm, Resident 4 was observed in his/her room using a nasal cannula and oxygen concentrator. S/he stated that s/he had more difficulty breathing recently and used oxygen continuously.? On 06/03/26 at 2:30 pm, Resident 4 was observed driving his/her electric wheelchair to the outside corner of the building near a bench.? Resident 4 had a nasal cannula in place attached to a portable oxygen tank. S/he was observed removing the nasal canula but did not turn off the oxygen tank prior to lighting and smoking cigarettes. On 06/03/26, between 2:49 pm and 4:35 pm, multiple staff interviews were conducted regarding Resident 4’s smoking status while receiving oxygen via nasal cannula. Multiple staff reported they had observed or were aware that the resident had smoked while oxygen was in use. The tank of concentrated oxygen and tube next to an open flame created a fire hazard. This placed residents at risk and constituted an immediate threat to residents’ health and safety. On 06/03/26 at 4:33 pm, Staff 1 (ED) and Staff 2 (Resident Services Coordinator) were notified of the observation. Staff 1 and Staff 2 created an immediate plan of correction, educated the resident on the risks of smoking with oxygen, and updated Resident 4's service plan to require staff to assist resident in turning off tank prior to smoking and immediately notify the Administrator if the resident was observed smoking with oxygen on. An immediate plan of correction to address the reasonable precautions was requested from Staff 1 (ED) on 06/03/26 at 4:33 pm. The plan of correction was received and accepted by the survey team on 06/03/26 at 6:19 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation. In an interview on 06/03/26 at 6:19 pm, the need to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents was discussed with Staff 1 and Staff 2. They acknowledged the findings.

1. The two residents discussed have given their cigarettes to be locked in the med cart. When they go out to smoke the MT will give them one and remove the oxygen tank. Upon returning inside the MT will put the oxygen tank back on. If the residents want to stay outside when finished, they will press their pendant, and we will bring the oxygen out to them. Both residents have agreed, and this is already in place. This has been communicated by ISPs to the staff. 2. Every smoker that lives here that uses oxygen will be evaluated for safely removing their oxygen before they go out to smoke. This will apply to any resident whose smoking status changes or oxygen use changes. The safety of smoking and use of oxygen will be evaluated with service plan updates. If they are unsafe, we will implement the same plan for them. This will be communicated to staff through ISPs and has already been communicated to current staff. We will also put this into the treatment section of the MAR as a PRN once we confirm that the MD order will match. Care staff will be informed through the ISP as well to notify the MT if there is a concern for safety moving forward. There will be mandatory training for staff on safe smoking and oxygen procedures on Monday 6/8/26. 3. This will be discussed at shift huddle daily for 2 weeks. Then we will monitor monthly for 3 months then quarterly and PRN. 4. The ED or the RN will be responsible for ensuring this plan is completed and used as needed for future residents.

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 observation, interview, and record review, it was determined the facility failed to notify the local Department office when an incident of abuse or suspected abuse occurred and failed to ensure investigations included all required components for 1 of 1 sampled resident (#4) who experienced misplacement of money. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 09/2025 with diagnoses including chronic obstructive pulmonary disease. The resident’s 03/01/26 through 06/01/26 record was reviewed, and the resident and staff were interviewed. The following was identified: Resident 4 went to the emergency room on 03/13/26. Upon his/her return to the facility, a progress note stated “[R]esident not happy. Went to [the] hospital last night due to being out of morphine. [S/he] came back this afternoon and realize[d] all [of] the money in [his/her]] wallet was gone and so was the money on [his/her] desk by [his/her] bed.” There was no documented evidence the facility immediately reported the incident to the local Department office. On 06/04/26 at 3:20 pm, Staff 1 (ED) confirmed he was unable to find evidence of reporting to the local Department office and was unable to find evidence of an investigation completed by the facility. The need to ensure all incidents of abuse, or suspected abuse, were reported to the local Department office and that the facility investigation included all required components was discussed with Staff 1 and Staff 6 (Business Office Manager) on 06/04/26 at 3:20 pm. They acknowledged the findings.

1. All current incident reports were reviewed for reportable incidents. 2. ED, Wellness Coordinator, and BOM attended the OHCA Abuse Prevention Summit 06/11/26. Reviewed the CBC Compliance Framework Guide regarding APS reporting and investigation with all staff 06/25/2026. 3. Daily Incident Report review at morning standup meetings with the Interdisciplinary Team. 4. Executive Director / Licensed Nurse

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

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents’ needs and preferences and provided clear direction to staff for 3 of 5 sampled residents (#s 1, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 04/2008 with diagnoses including Alzheimer’s disease and type 2 diabetes mellitus. The resident’s 01/14/26 to 06/01/26 clinical record was reviewed, interviews with staff were conducted, and observations were made. The service plan, dated 02/13/26, was not reflective of the resident’s current care needs or lacked clear instructions to staff in the following areas: * Instructions for the use of an air mattress; * Instructions regarding oral care; * Instructions for sensory status, including hearing impairment; and * Fall interventions. During the survey, it was observed the resident used an air mattress while in bed and had hearing impairment, as evidenced by the need for staff to repeatedly ask simple questions to communicate with the resident. On 06/03/26 at 1:20 pm, during an interview, Staff 5 (MT) confirmed the resident had a hearing impairment. The service plan did not include any instructions regarding the use of the air mattress. The need to ensure residents’ service plans were reflective of their needs and provided clear direction to staff was reviewed with Staff 1 (ED) and Staff 6 (Business Office Manager) on 06/04/26 at 10:55 am. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 09/2025 with diagnoses including chronic obstructive pulmonary disease. The resident’s 03/01/26 through 06/01/26 clinical record was reviewed, interviews with staff and the resident were conducted, and observations were made. The service plan, dated 03/05/26, was not reflective of the resident’s current care needs or lacked clear instructions to staff in the following areas: * Oxygen tank monitoring and reordering of supplies; * Power wheelchair cleaning and maintenance; and * Home health nursing services. The resident’s service plan stated the resident used oxygen as needed, though multiple staff and the resident stated during the survey oxygen was currently being used on a continuous basis. A home health nurse noted on multiple dates the resident had only one tank of oxygen remaining and supplies needed to be reordered. In an interview on 06/04/26 at 3:20 pm, Staff 1 (ED) stated the resident received automatic deliveries of oxygen. He acknowledged the resident appeared to be using more oxygen than s/he had in the past and, therefore, could be running low on oxygen prior to additional tanks being delivered. He acknowledged the service plan did not include instructions on who, when, or how oxygen should be ordered. The need to ensure residents’ service plans were reflective of needs and provided clear direction to staff was reviewed with Staff 1 and Staff 6 (Business Office Manager) on 06/04/26 at 3:20 pm. They acknowledged the findings. 3. Resident 1 was admitted to the facility in 03/2026 with diagnoses including type 2 diabetes. The resident’s 03/20/26 to 06/02/26 clinical record was reviewed, interviews with the resident and staff were conducted, and observations were made. The service plan, dated 04/16/26, was not reflective of the resident’s current care needs and preferences or lacked clear instructions to staff in the following areas: * Skin conditions including ongoing sores on his/her bottom, a rash and the surgical site from the catheter; * Toileting, including assistive device, location, and technique for toileting; and * Bathing, including assistive device and preferences for time of day and gender of caregiver. During an observation on 06/02/26 at 1:30 pm, Resident 1 was assisted by one caregiver for toileting assist. The resident backed his/her power chair into the shower while the caregiver applied powder to the seat of commode and was instructed by the resident to place a towel on the hardware of the commode for skin protection during the transfer. Resident 1 indicated there was no room to use the toilet and this was the method s/he used for toileting. During an interview on 06/02/26 at 11:44 am, Resident 1 showed the surveyor s/he had a sliding transfer tub bench for showering but indicated one of the caregivers did not like to use it. During an interview on 06/03/26 at 10:45 am, Staff 11 (CG) stated they preferred to use the commode instead for access to wash the resident’s bottom. The service plan did not provide clear instructions on which assistive device to use. The need to ensure service plans provided clear direction regarding the delivery of services and were reflective of the resident’s needs and preferences was discussed with Staff 1 (ED) and Staff 6 (Business Office Manager) on 06/04/26 at 2:04 pm. They acknowledged the findings.

1. 100% audit to be done and all issues fixed on current service plans. 2. IDT will take place weekly with all managers present. All managers will be trained on how to appropriately complete their section of the service plan 3. Weekly during IDT, Quarterly with SP updates, and with any significant change of condition 4. IDT team (ED,LN, Resident Care Coordinator, Medroom Manager, Life Enrichment, Maintenance Director).

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 consistently determine and document what action or intervention was needed for short-term changes of condition, communicate the action or intervention to staff on each shift, monitor the resident consistent with the resident’s evaluated needs, and document weekly progress until the condition was resolved for 2 of 5 sampled residents (#s 1 and 4) with changes of condition. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 03/2026 with diagnoses including type 2 diabetes. The resident's 04/16/26 service plan, 03/20/26 to 06/02/26 progress notes, and 03/27/26 through 05/30/26 outside provider visit notes were reviewed. For the following changes of condition, the facility failed to document the status of the condition at least weekly until resolved or failed to document whether the condition was resolved: * 03/20/26 – Rash to groin and pannus; * 03/20/26 – Surgical site from removal of suprapubic catheter; and * 03/21/26 – Three sores on the bottom. During an interview on 06/04/26 at 10:52 am, Staff 2 (Resident Services Coordinator) acknowledged the lack of monitoring at least weekly for the skin conditions, which included the status of the buttock wounds. The need to ensure the facility noted progress of the condition at least weekly until resolved was reviewed with Staff 1 (ED) and Staff 6 (Business Office Manager) on 06/04/26 at 2:04 pm. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 09/2025 with diagnoses including chronic obstructive pulmonary disease. The resident’s 03/01/26 through 06/01/26 clinical record was reviewed and interviews with staff and the resident were conducted. The following was identified: a. Resident 4 went to the emergency room on 03/13/26, and upon his/her return, a progress note stated, “[R]esident not happy. Went to [the] hospital last night due to being out of morphine. [S/he] came back this afternoon and realize[d] all [of] the money in [his/her]] wallet was gone and so was the money on [his/her] desk by [his/her] bed.” The resident experienced shortness of breath and staff documented the resident experienced an “anxiety attack” and required the use of PRN medication. There was no documented evidence that actions or interventions were determined and the resident was monitored through resolution of symptoms. b. On 05/07/26 an Interim Service Plan (ISP) was initiated stating the resident was experiencing depression and instructed staff to check on the resident three times per shift, ensure his/her laptop was working, and monitor for signs and symptoms of depression. There was no documented evidence of monitoring with weekly progress noted through resolution. In an interview on 06/02/26 at 2:36 pm, Resident 4 stated that his/her laptop was no longer working and s/he felt isolated at times as it was his/her primary source of entertainment. The need to ensure short-term changes of condition had interventions determined and documented, those interventions were communicated to staff on all shifts, and the resident was monitored, with progress noted weekly through resolution, was reviewed with Staff 1 (ED) and Staff 6 (Business Office Manager) on 06/04/26 at 3:20 pm. They acknowledged the findings.

1. Residents' ISP and monitoring were updated to weekly again. This is the Mosaic policy and standard. 2. ED and LN will review alert charting daily to ensure all concerns have been placed in the monitoring section as needed 3. Daily review of progress notes, weekly for residents with change of condition or skin issues. 4. Clinical team. (ED, LN, Resident Services Coordinantor, Medroom Manager).

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

Based on interview and record review, it was determined the facility failed to ensure information and interventions provided by on-site outside providers were communicated to staff and service plans adjusted if necessary and, following a resident's visit to an outside medical provider, information obtained from said provider was included in the resident's record for 2 of 3 sampled residents (#s 1 and 4) who received outside services. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 03/2026 with diagnoses including type 2 diabetes and was identified during the acuity interview on 06/01/26 as receiving home health services. Review of outside provider notes from 03/27/26 through 05/30/26 identified the following recommendations: * 04/03/26 – A HH RN note recommended to “Reinforce checking briefs many times daily ... Frequent position changes every 15 [minutes] in chair or sitting.”; * 04/06/26 – A HH OT note indicated, “Due to wounds recommend hourly brief checks due to urine incontinence...Also recommend trash bag for transfers to reduce sheering.”; and * 05/21/26 – A HH nursing note indicated “greenish discharge” from the suprapubic catheter and instructed staff to, “Please push fluids and call 911 if [s/he] becomes disoriented or confused.” There was no documented evidence the facility communicated these recommendations to direct care staff or that the service plan was adjusted to ensure continuity of care. The need to ensure staff were informed of on-site outside provider information and interventions, and the service plan adjusted if necessary, was reviewed with Staff 1 (ED) and Staff 6 (Business Office Manager) on 06/04/26 at 2:04 pm. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 09/2025 with diagnoses including chronic obstructive pulmonary disease. The resident’s 03/01/26 through 06/01/26 clinical record was reviewed, interviews with staff and the resident were conducted, and observations were made. The following was identified: On 04/16/26, the facility received a fax containing “pre-procedure instructions” to prepare the resident for surgery on 04/21/26. The procedure was stated to require anesthesia and included a bronchoscopy (viewing of the bronchial tubes via a camera inserted into the mouth and down the throat into the bronchial tubes) and lung biopsy. The pre-procedure instructions included modifications to the resident’s medications and ability to eat and drink the night and morning prior to surgery. The April 2026 MAR showed medications were administered according to the pre-procedure instructions, including administration of PRN acetaminophen (for pain) and PRN morphine (for shortness of breath) at 8:00 am on 04/21/26. The resident was scheduled to arrive for the procedure at 9:15 am on 04/21/26. There was no indication in the resident’s facility record of whether the resident underwent the procedure on 04/21/26 or the resident’s status following the procedure. Staff 2 (Resident Services Coordinator), Staff 5 (MT), and Staff 13 (MT) stated in separate interviews on 06/03/26 they were unaware of whether the resident had undergone surgery on 04/21/26. The need to ensure any information obtained from an outside provider, following a resident’s visit with said provider, was included in the resident’s record was reviewed with Staff 1 (ED) and Staff 6 (Business Office Manager) on 06/04/26 at 2:04 pm. They acknowledged the findings.

1. Service plans updated to reflect the recommendations of outside providers for both residents identified. 2. MT meeting to provide education on appropriate way to pull the providers recommendations and place them in an ISP for communication to care partners 3. All orders will be processed timely, using the 3rd check system. This will be reviewed weekly. 4. Clinical team. (ED, LN, Resident Services Coordinantor, Medroom Manager).

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991

Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment related to incontinence and personal care for 2 of 2 sampled residents (#s 1 and 3) whose care was observed. Findings include but are not limited to: 1. Resident 1 was admitted to the facility in 03/2026 with diagnoses including type 2 diabetes. a. On 06/02/26 at 1:30 pm, Staff 10 (CG) was observed donning gloves to provide incontinence care and replace catheter tubing due to catheter leakage. No observations were made of Staff 10 performing hand hygiene prior to donning gloves. Staff 10 applied powder to the commode, placed a towel on the end of the commode, removed the soiled brief and assisted the resident to transfer onto the commode from the wheelchair. Staff 10 used a soiled draw sheet from the resident’s wheelchair to wipe up urine that had leaked onto the footplate of the wheelchair and placed the draw sheet in the trash can. Staff 10 removed the trash bag, replaced with a new trash bag, left the resident’s room to dump the trash and returned to the room with the same soiled gloves. Staff 10 was not observed changing her gloves or performing hand hygiene and began prepping the catheter tubing, wiped the tip with an alcohol pad, and then inserted the tube into its sleeve. The need to ensure infection prevention and control protocols were followed was discussed with Staff 1 (ED) and Staff 6 (Business Office Manager) on 06/04/26 at 2:04 pm. They acknowledged the findings. b. Staff 11 (CG) was observed on 06/03/26, between 10:30 am and 10:50 am, to provide incontinence care to Resident 1. Staff 11 handled the resident’s clothing, brief, and urinal, emptied the catheter drainage bag into the urinal, and then emptied the urinal into the toilet. Staff 11 did not change gloves during these tasks. Staff 11 then applied a no-rinse foam cleanser to the resident’s abdominal fold area, cleaned the area with wipes, and applied cream after completing abdominal care. The resident was then turned to the side with staff’s direction. During the repositioning and turning process, Staff 11 wiped gloved hands with a wipe but did not change gloves before continuing care. Staff 11 proceeded to clean the resident’s buttocks and apply cream without changing gloves between clean and dirty tasks. Throughout the entire incontinence care process, Staff 11 did not change gloves. Upon completion of care, Staff 11 removed the gloves, but did not perform hand hygiene. The need to ensure infection prevention and control practices were followed during personal care was discussed with Staff 1 (ED) and Staff 6 (Business Office Manager) on 06/04/26 at 10:55 am. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 04/2008 with diagnoses including Alzheimer’s disease and type 2 diabetes mellitus. Staff 10 (CG) was observed on 06/03/26, between 11:00 am and 11:11 am, providing incontinence care to Resident 3. The resident was seated in a chair at the dining table near the kitchenette area in his/her room. Staff 10 initiated care by positioning the resident’s four-wheel walker in front of the resident and providing verbal direction to stand using the walker. Staff 10 then lowered the resident’s soiled brief and pants and instructed the resident to sit back down in the chair without placing a protective barrier or performing any cleansing. Staff 10 removed the soiled brief and pants and applied a clean brief while the resident remained seated in the chair. Staff 10 then instructed the resident to stand again and proceeded to clean the resident’s perineal and buttocks areas. Following incontinence care, Staff 10 continued to wear the same gloves while touching and adjusting the resident’s shoes and grooming the resident’s hair. Staff 10 did not change gloves between dirty and clean tasks or after completing incontinence care and before performing grooming tasks. Upon completion of grooming, Staff 10 removed gloves but did not perform hand hygiene. The need to ensure infection prevention and control practices were followed during personal care was discussed with Staff 1 (ED) and Staff 6 (Business Office Manager) on 006/04/26 at 10:55 am. They acknowledged the findings.

1. Joshua Johnson, Infection Control Specialist, re-took the training and the Mosaic Infection Control Policies and Procedures Manual reviewed at all-staff Monday 03/08/2026 by Joshua Johnson, Infection Control Specialist for Lakeland Senior Living. Added more hand sanitizing stations. 2. Mosaic Infection Control Policies and Procedures Manual will be reviewed with every new hire as part of their onboarding and sections will be reviewed at least every other month at an all-staff meeting. Hand hygiene competencies reviewed and signed 06/25/2026.Rounding to be done by management will be implemented. Training and education will be done on proper ways to clean up bodily fluids, training and education on proper way to perform catheter care, training and education on infection control manual, proper use of biohazard bags. 3. Monthly and as needed 4. Executive Director / Licensed Nurse

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments (1) MEDICATION AND TREATMENT ADMINISTRATION SYSTEMS. The facility must have safe medication and treatment administration systems in place that are approved by a pharmacist consultant, registered nurse, or physician.(a) The administrator is responsible for ensuring adequate professional oversight of the medication and treatment administration system.

Based on observation, interview, and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight of the medication and treatment administration system for 1 of 1 sampled resident (#4) whose oxygen use and narcotic medication was reviewed. The lack of adequate professional oversight and lack of a safe medication system, including the narcotic tracking system and failure to administer medications as prescribed, placed Resident 4 at unreasonable discomfort. Findings include, but are not limited to: Resident 4 was admitted to the facility in 09/2025 with diagnoses including chronic obstructive pulmonary disease. The resident’s 02/08/26 through 06/01/26 facility record was reviewed, and staff were interviewed. The following was identified: a. The resident had a signed physician order, dated 03/05/26, for morphine 10 mg/5 ml oral solution (for shortness of breath) to be administered once per day in the evening. Review of the 02/08/26 through 03/13/26 Controlled Substance Disposition log showed multiple discrepancies in recorded “remaining” quantities of the liquid morphine. The following discrepancies were identified: Staff documented removing 5 ml of morphine daily between 02/08/26 and 03/08/26 for the resident’s scheduled dose. On 03/08/26, the resident’s bottle was documented as having 30.5 ml remaining. On 03/09/26, after documenting removal of 5 ml for the resident’s scheduled dose, the resident’s bottle was documented as having only 5 ml remaining. In the margin of the log, a staff member had written “corrected count” and new “remaining” amounts from 02/14/26 and 03/08/26. The edit was not dated, and there was no additional documentation relating to either the incorrect documentation from staff or the missing morphine. On a separate page the resident was documented as having 2 ml of morphine remaining in a bottle last used on 02/13/26. On 03/09/26, an unidentified person wrote that at 3:00 pm s/he “waste[d]” 2 ml. A note in the margin, unsigned, stated “bottle empty, book says there is still 2 ml left.” There was no documented evidence showing where the medication went, how it was disposed of, or who disposed of it. The discrepancies above resulted in a failure to reorder the medication in a timely manner, which led to the resident missing two scheduled doses of the medication, on 03/11/26 and 03/12/26. Following the missed doses, the resident “requested to be sent out.” The resident was evaluated in the emergency room and treated with a morphine injection. The emergency room discharge instructions stated the physician had “sent a message to the administrator at [Resident 4’s] facility regarding our concerns about possible drug diversion.” In an interview on 06/04/26 at 3:20 pm, Staff 1 (ED) stated he was unaware of the 20 ml discrepancy noted on 03/09/26 or the edits documented in the Controlled Substance Disposition Log. He stated the facility had reported the missed morphine doses to Adult Protective Services but had not reviewed the medication system to ensure it was safe. In an interview on 06/04/26 at 11:45 am, Staff 2 (Resident Services Coordinator) stated she was unaware of any professional oversight of the narcotic tracking system. She stated a staff member should be reviewing the resident’s MARs quarterly at the same time service plans are updated. She acknowledged the reviews had not been occurring. The failure to ensure a safe medication system resulted in the resident experiencing unreasonable discomfort, including transport to the emergency room and immediate treatment for symptoms of shortness of breath via injection. There was no documented evidence that any changes were made to the medication system or narcotic tracking following the incident. Between 03/13/26 and 05/29/26, Resident 4’s Controlled Substance Disposition log, which included morphine, continued to contain errors, and there was a lack of professional oversight regarding the “remaining” amounts documented. b. The resident had a signed order, dated 03/05/26, for PRN oxygen to be administered at 4 liters per minute. The facility instructed staff, via the 03/05/26 service plan, that MTs would administer oxygen per the MAR; however, the 03/01/26 through 06/01/26 MARs were reviewed and did not include instructions for staff to administer oxygen. The service plan also instructed staff to ensure the resident’s oxygen concentrator was set to 2.5 liters per minute, not the 4 liters per minute as prescribed. On 03/27/26, the resident complained of shortness of breath and was transported to the emergency room. The emergency room physician documented on 03/28/26 a diagnosis “with hypoxemia [abnormally low level of oxygen in the blood], pulse oximetry reading down to 79 [normal range 98 to 100] on 3 [liters per minute of oxygen].” The resident was admitted to the hospital for 13 days. In an interview on 06/02/26 at 4:50 pm, Staff 3 (Regional RN) acknowledged discrepancies with Resident 4’s current signed order for oxygen and instructions to staff via his/her service plan. She acknowledged there was no indication of the use of PRN oxygen on the resident’s MAR and no indication in the resident’s evaluation of whether s/he could self-administer PRN oxygen or if MTs were responsible for administration. The facility failed to ensure adequate professional oversight related to oxygen use and the resident was admitted to the hospital and diagnosed with hypoxemia. The need to ensure a safe medication system, including adequate professional oversight of the medication and treatment administration system, was reviewed with Staff 1 and Staff 6 (Business Office Manager) on 06/04/26 at 3:20 pm. They acknowledged the findings.

1. This was a past medication issue with the morphine. The service plan updated with the correct oxygen information. 2. MT training on narcotic counting process, manager will audit a narcotic count weekly, education will be provided on policies for controlled substances. Orders will go through the 3rd check system with LN being the 3rd check. New 90 day orders will be sent to providers for signature to reconcile al medication lists 3. Weekly and as needed. 4. Executive Director / Licensed Nurse

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 medication and treatment orders were carried out as prescribed and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments the facility was responsible for administering for 4 of 4 sampled residents (#s 1, 2, 3 and 4) who were administered medications and treatments. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility 09/2025 with diagnoses of restless leg syndrome and overactive bladder. There was no documented evidence the facility had written, signed physician or other legally recognized practitioner orders documented in the resident's facility record for the following medications and treatments the facility was responsible to administer: * Mirabegron ER (for overactive bladder); * Ocuvite adult 50+ softgel (supplement); * Ropinirole HCL 1 mg (for restless leg syndrome); * Ropinirole HCL 2 mg (for restless leg syndrome); * Solifenacine (for overactive bladder); * Ondansetron ODT (for nausea); and * Rizatriptan (for migraines). The need to ensure signed physician's orders were in place for all medications administered was discussed with Staff 1 (ED) and Staff 6 (Business Office Manager) on 06/04/26 at 2:55 pm. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 04/2008 with diagnoses including Alzheimer’s disease and type 2 diabetes mellitus. The resident’s clinical record, dated 02/04/26 through 06/01/26, was reviewed, and the following was noted: a. There was no documented evidence the facility had written, signed physician or other legally recognized practitioner orders documented in the resident's facility record for the following treatments the facility was responsible to administer: * Calmoseptine (to protect skin); * Zinc cream (to protect irritated skin); and * Silicone barrier cream. b. Resident 3 had a physician's order, dated 05/07/26, to administer aluminum & magnesium hydroxide-simethicone 200-200-20 mg/5 ml every six hours as needed for indigestion. However, there was no evidence the order was transcribed to the MAR to carry out. c. Resident 3 had an order to administer morphine 5 mg every hour as needed for pain; however, conflicting information was identified on the resident’s MAR. One instruction indicated administration every hour, while another indicated every two hours. The need to ensure signed physician's orders were in place for all medications administered by the facility and were carried out as written was discussed with Staff 1 (ED) and Staff 6 (Business Office Manager) on 06/04/26 at 10:55 am. They acknowledged the findings. 3. Resident 1 was admitted to the facility in 03/2026 with diagnoses including type 2 diabetes. The resident’s clinical record, dated 03/20/26 through 06/02/26, was reviewed, and the following was noted: * On 03/21/26, Resident 1 was identified as having three “sores on [his/her] bottom.” The facility faxed the physician on 03/21/26 and requested “something to help sores’s [sic] are bleeding,” noted as “Urgent.” On 03/23/26 the physician ordered “zinc oxide cream or ointment (cream preferable) daily.” Additional instructions included, “Avoiding moisture (scheduled checks and change) and pressure (up/down schedule) to avoid skin damage.” There was no documented evidence a cream or ointment was applied daily until Desitin cream was noted on the MAR on 04/10/26, 18 days after the physician order. During an interview on 06/04/26 at 10:52 am, Staff 2 (Resident Services Coordinator) acknowledged the Desitin cream was the treatment the facility used in response to the physician’s order. She also acknowledged there was no documented evidence the physician instructions regarding scheduled brief checks and changes, and a schedule for pressure relief, had been carried out. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was discussed with Staff 1 (ED) and Staff 6 (Business Office Manager) on 06/04/26 at 2:04 pm. They acknowledged the findings. No additional documentation was provided. 4. Resident 4 was admitted to the facility in 09/2025 with diagnoses including chronic obstructive pulmonary disease. The resident’s 03/01/26 through 06/01/26 clinical record was reviewed and staff were interviewed. The following was identified: a. The resident had a signed order, dated 03/05/26, for Mucinex 600 mg tablet extended release (for chronic obstructive pulmonary disease), to be administered one tablet four times per day. On 05/02/26, the facility changed the medication administration via the MAR so the medication was administered two times per day. In an interview at 1:30 pm on 06/02/26 Staff 3 (Regional RN) stated she was unable to find an order for the decreased frequency of administration. On 06/03/26 at 10:15 am, Staff 2 (Resident Services Coordinator) confirmed she was unable to find an order for the medication to be administered two times per day. b. The resident had a signed order dated 03/05/26 which stated the resident should use oxygen via nasal cannula as needed at 4 liters per minute. However, there was no evidence the order was transcribed to the MAR to carry out. The service plan instructed staff to ensure the resident’s oxygen concentrator was set to 2.5 liters per minute. The resident’s concentrator was observed to be set to 3 liters per minute on 06/02/26 at 2:26 pm. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (ED) and Staff 6 (Business Office Manager) on 06/04/26 at 2:04 pm. They acknowledged the findings.

1. Getting new 90 day orders to reconcile medication records 2. Training and education on what proper order processing of medications using the 3rd check system. 3. With every new order coming in the LN will verify that it is porperly input. 4. Executive Director / Licensed Nurse

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 observation, interview, and record review, it was determined the facility failed to ensure a supportive device with restraining qualities was assessed by an RN, PT, or OT prior to use, failed to document other less restrictive alternatives were evaluated prior to the use of the device, caregivers were instructed on the correct use of and precautions for the device, and use of the device was included in the resident’s service plan for 1 of 1 sampled resident (#1) who had side rails on their bed. Findings include, but are not limited to: Resident 1 was admitted to the facility in 03/2026 with diagnoses including type 2 diabetes. Observations of the resident and the resident's room on 06/02/26 at 11:44 am identified Resident 1 had side rails in the up position on each side of the bed. A current assessment for the side rails was requested on 06/02/26, and a copy of the initial assessment, completed on 04/16/26, was provided. Review of the side rail assessment identified the following: * The assessment had been completed and signed by Staff 2 (Resident Services Coordinator). There was no documented evidence the assessment had been completed by an RN, PT, or OT for the use of side rails; and * There was no documented evidence other less restrictive alternatives were evaluated prior to the use of the side rails or that caregivers were instructed on the correct use of and precautions for the device. Additionally, review of the resident’s most recent service plan and temporary service plans did not include any instructions related to side rail use. During an interview on 06/03/26 at 11:45 am, Staff 2 confirmed she completed the assessment during a time they did not have a regularly scheduled RN. The need to ensure an assessment of assistive devices with restraining qualities was completed by an RN, PT, or OT and the documentation requirements for the use of such devices were discussed with Staff 1 (ED) and Staff 6 (Business Office Manager) on 06/04/26 at 2:04 pm. They acknowledged the findings.

1. Every apartment audited for all supportive devices. Those with devices records were audited for accuracy including the RN initiating the first assessment. 2. This will be a physical visit to each apartment as part of the quarterly service plan update to ensure families or residents have not put something in place we are unaware of. Training and education to all staff on what assistive devices are and the need to notify clinical management if they find a new device in use. 3. Quarterly and with change of condition. 4. Executive Director / Licensed Nurse

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 4 of 4 direct care staff (#s 9, 16, 17, and 18) demonstrated knowledge and performance in all required areas. Findings include, but are not limited to: Employee training records were reviewed on 06/02/26 with Staff 2 (Business Office Manager). There was no documented evidence Staff 9 (MT), hired 04/12/26, Staff 16 (CG), hired 04/07/26, Staff 17 (MT), hired 03/23/26, and Staff 18 (CG), hired 03/15/26, had demonstrated knowledge and performance of the following areas: * The role of service plans in providing individualized resident care; * Providing assistance with the activities of daily living; * Changes associated with normal aging; * Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition; and * Conditions that require assessment, treatment, observation and reporting. In an interview on 06/03/26 at 2:20 pm, Staff 2 (Resident Services Coordinator) confirmed the facility did not have evidence of staff demonstrating competency in all required areas within 30 days of hire. The need to ensure knowledge and performance in all required areas was demonstrated within 30 days of hire was reviewed with Staff 1 (ED) and Staff 6 (Business Office Manager) on 06/04/26 at 3:20 pm. They acknowledged the findings.

1. Frontline staff skills checklists reviewed at the all-staff meeting on 6/8/2026 to make sure everyone is current. 2. Skills checklist has been added to the training spreadsheet. The Businness Office Manager will put a reminder at day 29 of employment in her calendar and invite the direct supervisor and the Executive Direcctor so everyone has the reminder to collect the completed checklist. 3. At the 30 day point for every new hire. 4. Executive Director / Business Office Manager.

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 kitchen practices and protocols were in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: On 03/27/26, between 9:00 am and 11:00 am, the facility kitchen was observed to need cleaning and/or repair in the following areas: * Cutting boards – heavily scored, stained, non-cleanable; * Speed rack in walk-in refrigerator – food debris; and * Dish machine – wash and rinse temperatures were below minimum requirements. During an observation on 03/27/26 at approximately 10:00 am, Staff 1 (PIC/Dining Services Director) demonstrated the dish machine did not meet minimum temperature requirements for washing and rinsing. Staff planned to use the three-compartment sink for ware washing until the repair was made. The areas of concern were discussed with Staff 1 (PIC/Dining Services Director), Staff 2 (Executive Director) and Staff 3 (Regional Operations Director) at approximately 11:00 am on 03/27/26. Staff acknowledged the findings.

* Cutting boards – heavily scored, stained, non cleanable; 1. All scored cutting boards will be replaced. 2. This will be monitored daily by the cooks and any that need to be replaced will be brought to the attention of the PIC who will inform the ED. 3. Daily by the cooks, weekly by the PIC, and monthly by the ED. 4. ED/PIC * Speed rack in walk-in refrigerator – food debris 1. Speed racks cleaned immediately. 2. Cleaning schedule posted by the walk in to be filled out daily. 3. Daily by staff, weekly by PIC, and monthly by ED. 4. ED/PIC * Dish machine – wash and rinse temperatures were below minimum requirements 1. ED followed manufacturer's recommendation for switching to chemical disinfectant until water temps could be reached. 2. Faulty water heater to be replaced. 3. Daily temp logs will be appropriately kept by staff. PIC to check weekly and ED to review monthly. 4. ED/PIC

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 411-054-0028 (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 administrator or designee failed to immediately notify the local Department office, or the local AAA, of any incident of suspected abuse, promptly investigate all reports of suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse, for 1 of 1 sampled resident (#7) who reported neglect to the facility. Findings include, but are not limited to: Resident 7 was admitted to the facility in 09/2018 with diagnoses including type 2 diabetes mellitus, coronary artery disease, peripheral neuropathy and sleep apnea with CPAP (continuous positive airway pressure). At the resident’s request, this surveyor met with Resident 7 on 11/07/24 at 12:45 pm. During the interview, the resident reported that approximately one month ago, s/he fell in his/her room sometime after midnight. The resident stated it took the facility staff at least 30 minutes to respond after pressing the call pendant, during which time the resident said s/he was in severe pain. The resident provided a copy of a hand-written letter, titled “Injury Report”, s/he said s/he provided to Staff 1 (ED) on 10/29/24 – four weeks after the above incident. The document stated staff had not responded to the call pendant for “at least 30 minutes” during which time s/he was “screaming” and in “indescribable” pain. Resident 7’s report of being in pain while waiting 30 minutes for staff to respond represented an incident of suspected abuse which required the facility to immediately report the incident to the local Department office and investigate the incident to ensure the safety of residents. In an interview on 11/07/24 at 2:10 pm, Staff 1 confirmed Resident 7 had provided him with the above letter. He acknowledged he had not reported the incident as suspected neglect/abuse, investigated the report and taken measures necessary to prevent reoccurrence of abuse. The need to immediately notify the local Department office of any incident of suspected abuse, promptly investigate all reports of suspected abuse and take measures necessary protect residents and prevent the reoccurrence of abuse, was reviewed with Staff 1, Staff 2 (Wellness Manager/RN), Staff 3 (Resident Services Manager), Staff 6 (Regional Operations Support) and Staff 7 (Regional Payroll Support) on 11/08/24 at 9:30 am. They acknowledged the findings. The surveyor directed the facility to report the incident to the local APD office; confirmation the incident was reported was received on 11/08/24 at 10:35 am.

1. A thorough review of all incidents since survey was conducted to assure abuse and/or neglect was ruled out or incident was needing to be reported. Staff training using the survey process guide completed with all staff and copies provided to each staff member. 2. All grievances or complaints will be followed up on within 24 hours and reported to APS if needed. Auto e mails populate to the ED as soon as they are entered. 3.Daily and as needed 4. ED and or designee

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 411-054-0030 (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 maintain the kitchen in a sanitary manner and ensure food was prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). Findings include, but are not limited to: On 11/05/24 through 11/06/24 interviews with staff and observations of the facility kitchen, food storage areas, food preparation, and food service were conducted. The following was identified: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and grease was visible on or underneath the following: * Floor under/behind and between major equipment; * Floor under and around ware washing area; * Floor to wall transition throughout kitchen; * Floor and wire shelving in walk-in refrigerator; * Floor in walk-in freezer; * Dining room self-serve coffee, snack, and popcorn station counter tops and cabinetry; * Inside drawers and cabinets of dining room self-serve station; * Interior and exterior of popcorn machine; * Interior of clear plastic food display case; * Food carts for delivering resident meals; * Entry door and frame to the kitchen; * Exit door and frame to dining room; * Walls throughout kitchen; * Ceiling, vents, and fans above food prep and storage areas; * Interior and exterior of convection ovens; * Interior and exterior of ovens; * Flattop grill; * Interior and exterior of deep fryer; * Interior and exterior of large steamer; * Interior of stainless steel steam wells; * Interior of ice machine; * Exterior top of coffee machines; * Stand mixer; * Table mixer; * Can opener/housing; * Interior of drawer below steamer; * Interior of drawers in food prep areas; * Exterior of garbage cans; * Near/around ware washing area including caulk seal; and * Coffee, soda, and juice station counter tops and interior of sink. b. The following areas were noted in need of repair: * Entry door frame to kitchen had missing hardware; * Entry door to kitchen had missing hardware; * Exit door to dining room had missing hardware; * Baseboards throughout kitchen were not attached or falling off of the wall, including under the ware wash areas, food prep stations, and kitchen entrance and exit door; * Stand mixer casing; * Multiple cooking and serving tools and utensils; * Floor drain by walk-in refrigerator was not sealed; * Ware wash area caulking was broken and missing sections; and * Walk-in refrigerator door was missing hardware to keep door securely closed. c. There were several open food packages in the dry storage, walk-in refrigerator and walk-in freezer. d. The temperature of prepared food items was not consistently measured and food items were not cooked to the required minimum internal cooking temperatures. e. Food prep areas and tools used were not properly sanitized in-between handling and preparing potentially hazardous food. f. Multiple staff were handling clean and dirty dishes, serving residents food, and/or preparing food without hair restraints. g. Multiple staff entered and exited the kitchen without practicing hand hygiene. h. Multiple potentially hazardous food items were observed in cold food storage areas uncovered or unsealed, unlabeled, without open dates, and/or without use by dates. i. Staff did not check and were unaware how to properly check the surface sanitizer solution concentration to ensure sanitizer was dispensing at correct parts per million (PPM) for sanitizing buckets, ware wash machine, and three-compartment sink. j. Staff 4 (Dining Services Manager) stated he prepared eggs to order, that included soft yolk. The facility did not have pasteurized eggs available. k. Staff were observed to eat while preparing food for residents. On 11/06/24 at 1:55 pm, Staff 4 toured the kitchen with this surveyor and acknowledged areas that were not clean and/or in good repair. Safe food handling practices and infection control were discussed. On 11/06/24 at 4:15 pm, Staff 1 (ED) and Staff 6 (Regional Operations Support) toured the kitchen with this surveyor and reviewed areas of the kitchen that were not clean and in good repair and were made aware of concerns identified in food handling practices and infection control. On 11/07/24 at 8:10 am, a walkthrough of the kitchen was completed and the areas needing cleaning had substantially improved. The need to ensure the kitchen was maintained in a sanitary manner and food was prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules) was reviewed with Staff 1, Staff 2 (Wellness Manager/RN), Staff 3 (Resident Services Manager), Staff 6, and Staff 7 (Regional Payroll Support) on 11/08/24 at 10:55 am. They acknowledged the findings.

1. a. Full deep clean of kitchen addressing all areas identified during survey. b. Hardware on entry/exit doors to kitchen replaced. * Baseboards identified have been repaired *Stand mixer casing part ordered shipped on 11/27/2024 *Cooking and serving utensils that had wear were disposed of *Flooring repaired and drain by walk in re sealed. *Hardware for walk in replaced c. All open food packages in dry storage, walk in refrigerator and freezer was disposed of. d. Temperature log in place for all meals and reviewed to assure all food is cooked to the required temperature. e. Sanitizing wipes in place for use on utensils in-between handling and preparing potentially hazardous food. f & g. All staff re trained on proper handwashing techniques between clean and dirty. Hair and beard restraints ordered and in place for all kitchen staff and any serving staff. h. All items in food storage areas that were missing dates, covers or label's have been disposed of and all items now have dates, covers and label's. i. Chemical supplier reviewed sanitizing solutions with dining services manager and ED to assure proper PPM are accurate for sanitizing buckets and three compartment sinks. j. Pasteurized eggs ordered and in place for soft cook egg use. k. Reviewed with Dining Services Manager it is not appropriate to sample/eat food while on the line. 2. Dining services manager will re attend Serv Safe for review of proper kitchen etiquette and expectations. CBC kitchen inspection form will be utilized weekly by different department managers and reviewed by ED and dining services manager to assure areas identified are immediately corrected and or addressed. 3. Weekly 4. Dining servcies manager and ED or designee

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

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#3) and side rail evaluations were completed for 1 of 1 sampled resident (#5) whose side rail evaluations were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 09/2024 with diagnoses including urinary retention and use of a catheter. The resident’s move-in evaluation dated 09/24/24 was reviewed and the following required elements were not addressed: * Customary routines including sleeping, eating, and bathing; * Interests, hobbies, social, and leisure activities; * Physical health status; * Personality; * Dental status; * Ability to manage medications; * Pain including pharmaceutical and non-pharmaceutical interventions; * Nutrition habits, fluid preferences, and weight if indicated; * Emergency evacuation ability; * History of dehydration; * Recent loses; * Unsuccessful prior placement; and * Environmental factors including lighting and room temperature. The need to ensure move-in evaluations addressed each required element was reviewed with Staff 1 (ED), Staff 2, Staff 3, Staff 6 (Regional Operations Support) and Staff 7 (Regional Payroll Support) on 11/08/24 at 10:55 am. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 05/2017 with diagnoses including diabetes mellitus type 2, morbid obesity, and use of a catheter. The resident was observed to have bilateral quarter-length siderails on his/her bed. The resident’s record was reviewed, and the following was identified: On 11/07/24 at 1:02 pm, Staff 2 (Wellness Manager/RN), Staff 3 (Resident Services Manager) and Staff 8 (Caregiver Supervisor) stated they were unaware the resident had siderails and Staff 2 confirmed there was not a completed evaluation for the resident’s use of siderails. The need to ensure residents were evaluated for the use of siderails was reviewed with Staff 1 (ED), Staff 2, Staff 3, Staff 6 (Regional Operations Support) and Staff 7 (Regional Payroll Support) on 11/08/24 at 10:55 am. They acknowledged the findings.

1. Res #3, evaluation was updated to meet the rule on the 30 day evaluation prior to exit. A review of all other admissions during the 30-day time frame were audited to assure evaluations meet the rule. 2. All new move in evaluation will be second checked by clinical team prior to admission ensuring all areas are addressed appropriately. 3. Upon move in and evaluation updates. 4. Clinical team, ED or designee.

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

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

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear directions to staff regarding the delivery of services for 1 of 6 sampled residents (#5) whose service plans were reviewed. Findings include, but are not limited to: Resident 5 was admitted to the facility in 05/2017 with diagnoses including diabetes mellitus type 2, morbid obesity, and use of a catheter. The resident was observed to have bilateral quarter-length siderails on his/her bed throughout the survey. Observations were made of the resident's care from 11/05/24 through 11/08/24. Interviews with the resident, facility staff and the residents outside provider were conducted. The current service plan dated 09/10/24 was reviewed. Resident 5's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Use of bilateral quarter-length siderails including instructions for use and monitoring for safety; * Use of nebulizer including instruction to staff; * Use of a hospital bed; * Dental status and lack of denture use; * Instructions for monitoring of chronic skin conditions and provision of treatments; * Preference of when room door was propped open and/or locked; and * Use of eye glasses. The need to ensure the service plan reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (ED), Staff 2 (Wellness Manager/RN), Staff 3 (Resident Services Manager), Staff 6 (Regional Operations Support) and Staff 7 (Regional Payroll Support) on 11/08/24 at 10:55 am. They acknowledged the findings.

1. Res #5 service plan was updated to reflect the bed rails, use of glasses, dentures and directions for the use of the nebulizer. An audit of all resident's service plans completed ensuring accuracy of resident specific care needs have clear instructions and care planned. 2. Quarterly and as needed checklist implemented with clinical team and care staff to thoroughly review each component of the service plan for resident specific needs. 3. Quarterly and as needed. 4. Clinical team and ED or designee

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

Based on observation, interview, and record review, it was determined the facility failed to coordinate on-site health services with outside providers, adjust the service plan as necessary, and ensure staff were informed of new interventions for 1 of 4 sampled residents (#1) who received outside services. Findings include, but are not limited to: Resident 1 was admitted to the facility in 10/2023 and readmitted in 8/2024 with diagnoses including left leg amputation and intervertebral disc disorders. The resident's progress notes, outside provider notes and interim service plans (ISPs) dated 08/03/24 to 11/04/24, and the resident’s most current service plan dated 10/10/24, were reviewed and the following was identified: * A significant change of condition note dated 09/10/24, completed by Staff 2 (Wellness Manager/RN), indicated Resident 1 had a transfer pole that needed to be “put up by his/her bed.” * A home health provider note dated 09/23/24 indicated Resident 1 “needs transfer pole put up.” * Resident 1’s service plan dated 10/10/24 and reviewed ISP’s lacked information regarding the transfer pole. Observations during the survey revealed no transfer pole was installed in the resident’s apartment. During an interview on 11/06/24 at 9:00 am, Staff 2 stated the facility had a transfer pole for the resident prior to his/her amputation surgery in 08/2024 but acknowledged the pole had not been installed. The need to ensure coordination and continuity of care with outside provider recommendations was discussed with Staff 1 (ED), Staff 6 (Regional Operations Support), and Staff 7 (Regional Payroll Support) on 11/07/24 at 5:00 pm. They acknowledged the findings.

1. Res #1 outside provider recommendation was implemented prior to survey exit. A review of all outside provider notes within this time frame were audited to assure recommendations were followed up and implemented as requested. 2.Triple check system in place and clinical team reviews weekly at IDT to assure timely implementation of all outside provider recommendations. 3. During the triple check process and weekly at IDT 4. Clinical team and ED or designee.

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

OAR 411-054-0055 (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 when a resident refused to consent to orders for 2 of 3 sampled resident (#s 4 and 5) who had documented medication refusals. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 12/2023 with diagnoses including shortness of breath. Resident 4’s clinical records and MAR were reviewed during the survey. The resident had signed physician orders to inhale ipratropium albuterol via nebulizer three times a day. The MAR indicated that the resident refused the medication 20 times from 10/01/24 through 11/04/24. There was no documented evidence the facility notified the prescriber each time the resident refused to consent to the orders. On 11/04/24, the failure to notify prescribers of refusals was discussed with Staff 1 (ED), Staff 6 (Regional Operations Support), and Staff 7 (Regional Payroll Support). They acknowledged the findings. 2. Resident 5 was admitted to the facility in 05/2017 with diagnoses including diabetes mellitus type 2, morbid obesity, and use of a catheter. Resident 5’s clinical records and 10/2024 MAR were reviewed during the survey. Resident 5 had signed physician orders for the following: * Desitin daily defense 13% cream to be applied two times daily; * Nystatin external cream to be applied twice daily; and * Nystatin external powder to be applied four times daily. The MAR indicated the resident refused the above orders on 140 occasions between 10/01/24 and 10/31/24. There was no documented evidence the facility notified the prescriber of the refusals. The need to ensure prescribers were notified of resident refusals was reviewed with Staff 1 (ED), Staff 2 (Wellness Manager/RN), Staff 3 (Resident Services Manager), Staff 6 (Regional Operations Support) and Staff 7 (Regional Payroll Support) on 11/08/24 at 10:55 am. They acknowledged the findings.

1. Res #5 and Res #4 providers notified of any medication or treatment refusals, medicaitons unavaliable or missed medications. 2. All resident providers have been faxed for clarificaiotn on how often they would like to be notified of any missed medicaiton, medication refusal or medicaiton unavialable. 3. Quartley upon 90 day medication orders. 4. Clincal team, ED or designee.

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 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff (6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF. (a) Annual infectious disease training requires the following: (A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training. (B) Annual in-service training must be documented in the employee record. (b) Biennial LGBTQIA2S+ training requires the following: (A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff. (i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite. (ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. (vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state. (D) The proposal for training submitted by a facility, entity, or individual shall include: (i) The regulatory criteria described in paragraph (C) of this section as part of the proposal. (ii) The following elements must be included in the proposal: (I) A statement of the qualifications and training experience of the facility, individual or entity providing the training; (II) The proposed methodology for providing the training either online or in person. (III) An outline of the training. (IV) Copies of the materials to be used in the training. (iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision. (c) Annual Home and Community-Based Services (HCBS) training requires the following: (A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations. (B) Annual in-service training must be documented in the employee record. (C) These annual trainings will be required as of April 1, 2025. (7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF. (a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire. (b) Requirements for annual in-service dementia training: (A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care. (B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter. (C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above. (D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia. (E) The facility shall determine the competency of direct care staff in dementia care in the following ways: (i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19). (ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff. (iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency. (8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process.

Based on interview and record review, it was determined the facility failed to ensure 1 of 2 long-term non-direct care staff (#4) completed annual infectious disease training. Findings include, but are not limited to: Staff training records were reviewed on 11/06/24 at 8:40 am with Staff 15 (Business Office Manager) and revealed there was no documented evidence Staff 4 (Dining Services Manager), hired on 12/13/19, completed annual training on infectious disease outbreak and control. The need to ensure long-term non-direct care staff completed the required annual infectious disease training was discussed with Staff 1 (ED), Staff 6 (Regional Operations Support) and Staff 7 (Regional Payroll Support) on 11/07/24 at 5:00 pm. They acknowledged the finding.

1. Full employee audit completed to assure no HR or pre service missing documents are missing or out of date. 2. Auto emails related to HR missing documents and all requiered training documents will be reviewed daily to assure on going compliance. 3. Daily and upon any new hire 4. Business office manager, ED or designee.

OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff (6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF. (a) Annual infectious disease training requires the following: (A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training. (B) Annual in-service training must be documented in the employee record. (b) Biennial LGBTQIA2S+ training requires the following: (A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff. (i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite. (ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. (vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state. (D) The proposal for training submitted by a facility, entity, or individual shall include: (i) The regulatory criteria described in paragraph (C) of this section as part of the proposal. (ii) The following elements must be included in the proposal: (I) A statement of the qualifications and training experience of the facility, individual or entity providing the training; (II) The proposed methodology for providing the training either online or in person. (III) An outline of the training. (IV) Copies of the materials to be used in the training. (iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision. (c) Annual Home and Community-Based Services (HCBS) training requires the following: (A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations. (B) Annual in-service training must be documented in the employee record. (C) These annual trainings will be required as of April 1, 2025. (7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF. (a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire. (b) Requirements for annual in-service dementia training: (A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care. (B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter. (C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above. (D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia. (E) The facility shall determine the competency of direct care staff in dementia care in the following ways: (i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19). (ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff. (iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency. (8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair.

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair, for 2 of 2 sampled residents (#s 2 and 4) whose apartments were observed during the survey. Findings include, but are not limited to: During the survey, the carpet in the living rooms of Resident 2 and 4’s apartments was observed to have large, soiled areas. In an interview on 11/06/24, Staff 5 (Maintenance Manager) stated the facility had not updated its carpet cleaning schedule to its new software system and acknowledged Resident 2 and 4’s carpets had not been cleaned recently. In an interview on 11/06/24, Staff 1 (ED) provided a record of the facility’s previous carpet cleaning schedule which indicated Resident 2 and 4’s carpets had last been cleaned in 04/2024. The need to ensure all interior materials and surfaces were kept clean and in good repair was reviewed with Staff 1, Staff 2 (Wellness Manager/RN), Staff 3 (Resident Services Manager), Staff 6 (Regional Operations Support) and Staff 7 (Regional Payroll Support) on 11/08/24. They acknowledged the findings.

1. Res # 2 & #4 carpets were deep cleaned. All other high traffic aparments were addressed and cleaned. 2. Carpet cleaning schedule has been implemented. All high traffic carpets and flooring have additional cleaning schedule in place. 3. Quarterly and as needed. 4. Maintenance Manager, ED and or designee.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 12/01/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day