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 This Rule is not met as evidenced by: Based on record review and interview, it was determined the facility failed to ensure the resident’s move-in evaluations addressed all required elements for 1 of 1 sampled resident (#1) whose move-in evaluation was reviewed. Findings include, but are not limited to: Resident 1 was admitted to the facility in 11/2025 with diagnoses including unspecified dementia, repeated falls, clavicle fracture, and rheumatoid arthritis. The initial evaluation failed to address the following elements with sufficient information to develop an initial service plan: * Gender identity; * Customary routines and preferences, including sleeping and eating; * Social interests; * Cultural preferences; * Cognition, including memory and confusion; * Communication and sensory, including hearing, vision, and speech; * Activities of daily living, including bowel and bladder management and dental status; * Pain, including pharmaceutical and non-pharmaceutical interventions and how a person expresses pain or discomfort; * Nutrition habits; and * Review of risk indicators, including complex medication regimen. The move-in evaluation was reviewed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 11/20/2025 at 12:10 pm. They acknowledged the information

C252 OAR 411-054-0034 (1-6) Resident Move-In and Eval: Resident evaluation 1. Resident 1 is no longer a resident of the community. 2. All new move-in evaluations have been reviewed for required elements, service plans were updated to reflect any updates to move-in evaluation. 3. Health Service Director and Community RN will review new move-in evaluations prior to move-in and quarterly to assure completeness. 4. Administrator will monitor performance and make appropriate adjustments through the QAPI process for three months and quarterly thereafter.

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 This Rule is not met as evidenced by:

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of the resident’s needs and preferences, provided clear instructions to staff regarding the delivery of services, and were implemented for 3 of 6 sampled residents (#s 1, 5, and 6), whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 11/2025 with diagnoses of dementia, repeated falls, clavicle fracture, and rheumatoid arthritis. Review of the resident's record, including the most current service plan, dated 11/04/2025, observations of the resident, and interviews with the resident and care staff indicated the following: Multiple observations throughout the survey indicated the resident was unable to independently locate areas of interest in the facility (e.g., activities, the dining room, his/her apartment, his/her friend’s apartment, and the laundry room). In an interview on 11/19/25, the resident acknowledged having difficulty remembering directions to various locations in the building and information s/he had already been told. An interview with Staff 7 (CG) on 11/18/2025 indicated the resident had not been able to remember directions and needed guidance to the dining room and activities. S/he also needed reminders to go to meals and should be escorted to the dining room and got confused sometimes and ended up on the other side of the building. The current service plan lacked information about the resident’s memory status and confusion and lacked specific instructions for how staff should provide assistance, given his/her memory issues and confusion, in the following areas: * Safety; * Mobility; * Ambulation device used; * Dining; * Life enrichment; * Bathing; * Pain management; and * Housekeeping/laundry. In addition, the service plan lacked information about the resident’s desire to participate in art activities and to volunteer at a local music venue. The need to ensure Resident 1's service plan was reflective of his/her current needs and preferences, and provided clear instructions to staff, was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 11/20/25. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 07/2023 with diagnoses including dementia, cerebral atherosclerosis, and major depressive disorder. The resident’s record was reviewed, including the current service plan, dated 09/22/25, observations were made, and interviews with staff were conducted. The following was identified: The service plan was not reflective of the resident’s current care needs, lacked clear instruction, and/or was not implemented in the following areas: * Dining assistance, including as-needed cueing and encouragement; * Meal preparation, including cutting up food prior to serving the resident; * Escorts to and from the dining room; * Ability to self-direct participation in activities and request an escort; * Evening toileting schedule and number of staff needed; * How the resident expressed pain; * Personal hygiene assistance, including number of staff needed; * Sleep preferences including use of recliner for a bed; * Compression stocking use; * Shower schedule and number of staff needed; * Instruction related to excess soiled laundry and additional services completed; * Daily vitals; and * Evacuation status. The need to ensure service plans were reflective of the residents’ current care needs, included clear instructions to staff, and/or were implemented was reviewed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 11/20/25 at 1:08 pm. They acknowledged the findings. 3. Resident 6 was admitted to the facility in 07/2025 with diagnoses including neuropathy, chronic obstructive pulmonary disease, atherosclerotic heart disease of native coronary artery, and thrombocytopenia. The resident’s record was reviewed, including the 11/14/25 service plan, observations were made, and interviews with staff were conducted. The following was identified: The service plan was not reflective of the resident’s current care needs, lacked clear instruction to staff, and/or was not implemented in the following areas: * Daily weights; * Vitals three times daily; * Cleaning instructions for oxygen equipment; * Current skin conditions; * Dressing assistance, including use of compression stockings and number of staff needed; * Personal hygiene assistance needed; and * Evacuation status. The need to ensure service plans were reflective of the residents’ current care needs, included clear instructions for staff, and/or were implemented, was reviewed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 11/20/25 at 1:27 pm. They acknowledged the findings.

1/19/20OAR 411-054-036 (1-4) Service Plan: General 1. Residents #’s 1, 5, 6 no longer reside at the community. 2. All service plans were audited for accuracy reflecting residents needs and preferences and provides clear direction to staff regarding delivery of services. Additions were added to current service plans. 3. Administrator or designee will review quarterly service plans weekly for three weeks and then quarterly thereafter to assure compliance with accuracy and completeness. 4. Administrator will monitor performance and make appropriate adjustments through the QAPI process for three months until substantial compliance is met and then quarterly thereafter.

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by:

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure actions or interventions were determined, documented, and communicated to staff on each shift for short-term changes of condition, with weekly progress noted through resolution, for 4 of 6 sampled residents (#s 3, 4, 5, and 6) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 01/2022 with diagnoses including Type 2 diabetes. The resident’s clinical record was reviewed. Resident 3 experienced the following changes of condition between 08/17/25 and 11/17/25: * On 09/20/25 the resident had a biopsy to the left arm and left thigh. A progress note on 09/25/25 noted the RN would assess once a week “until healed.” After 09/25/25 there was no documented evidence the site was monitored until 10/09/25, when Staff 3 noted the “biopsy sites are healed.” * On 09/25/25 the resident had a lumbar nerve block procedure for pain relief. The resident was put on alert charting. A progress note on 09/27/25 noted, “If procedure site becomes red or swollen, or if pain increases, please call … Pain center.” There was no documented evidence the facility monitored the procedure site at least weekly until resolution. In an interview on 11/19/25 at 10:25 am, Staff 3 (RN) indicated she did not have the weekly skin documentation for the above skin conditions and indicated “it was an oversight.” No further documentation was provided. The need to ensure changes of condition were monitored, with at least weekly documentation, until resolution was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 11/20/25 at 12:50 pm. They acknowledged the findings. 2. Resident 4 was admitted to the facility on 07/2022 with diagnoses including hypertension. The resident’s clinical record was reviewed. Resident 4 experienced the following changes of condition between 10/17/25 and 11/17/25: * On 10/17/25 the resident reported a fall and sustained a bruise and subsequent fracture to the right side of his/her face. Later that same day, the resident was admitted to the hospital and returned to the facility on 10/23/25 following a gastrointestinal bleed. A progress note from 10/23/25 noted “large, significant bruising on the inner aspect of both arms” from the injections at the hospital. A 10/27/25 progress note from Staff 3 (RN) indicated “scrapes and bruising on [his/her] R [right] side of face and arms … RN will check wounds next week.” After 10/27/25, there was no documented evidence the bruising in the three areas was monitored weekly through resolution. In an interview on 11/19/25 at 10:25 am, Staff 3 (RN) indicated, “I know I was looking at it,” but was not able to provide documented evidence the skin conditions were monitored at least weekly until resolution. The need to ensure monitoring of changes of condition was documented at least weekly until resolution was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 11/20/25 at 12:50 pm. They acknowledged the findings. 3. Resident 6 was admitted to the facility in 07/2025 with diagnoses including neuropathy, chronic obstructive pulmonary disease, atherosclerotic heart disease of native coronary artery, and thrombocytopenia. The resident’s record was reviewed, observations were made, and interviews with staff were conducted. There was no documented evidence the facility had developed and documented actions or interventions, communicated the actions or interventions to staff on all shifts, or documented weekly progress through resolution for the following changes of condition: * On 09/12/25 staff noted an increase in edema in the resident’s legs and a weight gain; * On 10/17/25 staff noted a “new” wound on the resident’s right heel; * On 10/21/25 staff noted they observed blood on the resident’s right toe; * On 10/21/25 staff noted the resident “passed out” in his/her wheelchair and was unrousable; and * On 11/15/25 staff noted the resident had “frozen moments” and required three staff to transfer him/her. On 11/19/25 at 1:30 pm, Staff 2 (Health Services Director) confirmed there was no additional documentation for the above changes of condition. The need to ensure changes of condition had actions or interventions determined, documented, and communicated to staff on each shift, with weekly progress noted through resolution, was reviewed with Staff 1 (Administrator) and Staff 2 on 11/20/25 at 1:27 pm. They acknowledged the findings. 4. Resident 5 was admitted to the facility in 07/2023 with diagnoses including dementia, cerebral atherosclerosis, and major depressive disorder. The resident’s record was reviewed, observations were made, and interviews with staff were conducted. The following was identified: a. On 10/27/25 the resident experienced a fall with injuries to his/her head and knee. There was no documented evidence the facility developed and implemented interventions for the fall or injuries, communicated the interventions to staff, or monitored the condition through resolution. b. On 11/03/25 the resident experienced a fall and had complaints of hip pain. A temporary service plan, dated 11/03/25, noted the resident had a fall and had complaints of pain; however, there was no documented evidence the facility developed and implemented interventions as a result of the fall and monitored the condition through resolution. On 11/18/25 at 2:46 pm, Staff 1 (Administrator) confirmed there was no documentation related to the resident’s injury fall on 10/27/25. The need to ensure actions or interventions were determined, documented, and communicated to staff on each shift for short-term changes of condition, with weekly progress noted through resolution, was reviewed with Staff 1 and Staff 2 (Health Services Director) on 11/20/25 at 1:08 pm. They acknowledged the findings.

OAR 411-054-0040 (1-2) Change of Condition Monitoring: 1.Resident number 3 and 4 will be evaluated for current status and healthcare needs. To include a review of existing temporary service plans will determine if those areas have been resolved, or if weekly documentation needs to continue. If so, weekly documentation to resolution will be completed 2. All residents will be audited for active temporary service plans and evaluated if these temporary service plan areas are resolved. If so, documentation of individual resident evaluations will be completed to resolve the Temporary Service Plan and update the permanent Service Plan as applicable. If temporary Service Plans are still active, an evaluation will be completed of the individual resident to determine their current status and evaluation and documentation will be completed weekly and documented in the resident’s clinical record until resolution. 3. The 24- hour Alert charting process policy and procedure will be reviewed and appropriate staff in-serviced on the components of this policy and procedure to include continued evaluation and documentation of the resident status until any resident health status or need is resolved. 4. Administrator will monitor performance and make appropriate adjustments through the QAPI process for three months until substantial compliance is met and then quarterly thereafter.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by:

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure a timely RN assessment was completed for a significant change of condition that included findings, resident status, and interventions made as a result of the assessment for 2 of 3 sampled residents (#s 5 and 6) who experienced significant changes of condition. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 07/2025 with diagnoses including neuropathy, chronic obstructive pulmonary disease, atherosclerotic heart disease of native coronary artery, and thrombocytopenia. The resident’s record was reviewed, observations were made, and interviews with staff were conducted. The following was identified: On 10/21/25, Resident 6 experienced an unconscious episode, was unrousable, and was admitted to the hospital. The resident was out of the facility from 10/21/25 through 11/13/25 and returned with a diagnosis of pneumonia, requiring the assistance of two staff to complete ADL cares and the use of oxygen at night. This constituted a significant change of condition for which an RN assessment was required. There was no documented evidence a significant change of condition assessment was completed by an RN, including findings, resident status, and interventions made as a result of the assessment. On 11/19/25 at 1:30 pm, Staff 2 (Health Services Director) confirmed an RN assessment had not been completed for this significant change of condition and stated one would be completed that day. The need to ensure an RN assessment was completed for a significant change of condition, including findings, resident status, and interventions made as a result of the assessment, was reviewed with Staff 1 (Administrator) and Staff 2 on 11/20/25 at 1:27 pm. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 07/2023 with diagnoses including dementia, cerebral atherosclerosis, and major depressive disorder. The resident’s record was reviewed, and interviews with staff were conducted. The following was identified: The resident was noted to have cognitive decline, required additional ADL care, and on 09/24/25 was admitted to hospice services. On 09/30/25 an RN assessment was completed; however, the assessment lacked interventions made as a result of the assessment. On 11/19/25 at 3:09 pm, Staff 2 (Health Services Director) confirmed the RN assessment was not timely and lacked interventions made as a result of the assessment. The need to ensure an RN assessment was completed for a significant change of condition, including findings, resident status, and interventions made as a result of the assessment, was reviewed with Staff 1 (Administrator) and Staff 2 on 11/20/25 at 1:08 pm. They acknowledged the findings.

OAR 411-054-0045 (1) (a-f)(A)(C-F) Resident Health Services. 1. Residents 5 and 6 no longer reside in the community. 2. See C270. Through the facility resident updated evaluations being completed on all current resident’s , any evaluations that results in a significant change of status will require an RN assessment to be completed as soon as this is determined. The facility RN will be inserviced on the requirements of RN assessment for significant change of condition. The Health Services team will also be inserviced regarding the requirement to notify the RN of a change in status initiating an RN assessment as required for both short term and long term changes in condition. 3. Changes of condition will be monitored as needed at clinical review meeting. 4. The Administrator and Health Services Director will monitor for resident changes in condition daily through their facility stand up process.Facility will monitor performance and make appropriate adjustments through the QAPI process for three months or until substantial compliance is met and then quarterly thereafter.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by:

OAR 411-054-0055 (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. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 1 of 1 sampled resident (#3) who had documented medication refusals. Findings include, but are not limited to: Resident 3 was admitted to the facility in 01/2022 with diagnoses including Type 2 diabetes. The resident's 08/17/25 through 11/17/25 MARs and progress notes were reviewed and revealed the resident refused to consent to orders for the following medication: * Erythromycin 5 mg/gm drops (for dry eyes) on 39 occasions. In an interview on 11/18/25 at 3:35 pm, Staff 2 (Health Services Director) indicated Resident 3 had a history of refusing this medication. The facility had notified the physician in 4/2025 of the refusals and requested the medication be discontinued “but the doctor never responded.” The 08/2025 through 11/2025 clinical records revealed the resident continued to intermittently refuse the medication. There was no documented evidence the prescriber was notified after each refusal for the medication. The need to ensure the facility notified the physician or other practitioner if the resident refused consent to an order was discussed with Staff 1 (Administrator) and Staff 2 on 11/20/25 at 12:50 pm. The findings were acknowledged.

OAR 411-054-0055 (1)(j-k) Systems: Right to Refuse 1.Resident #3's primary care physician was notified of refusals and adjustments made according to doctors instruction. 2.All resident Medication Administration records will be audited for refusals. Refusals will be reported to residents primary care physician and recorded in the client record. Medication Administration record will be updated and implemented as ordered. 3.Health Services Director will review refusals at through clinical stand up meetings 4. Administrator will monitor performance and make appropriate adjustments through the QAPI process for three months until substantial compliance is met and then quarterly thereafter.

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. This Rule is not met as evidenced by:

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure the resident’s individual ABST evaluation accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan, for 3 of 6 sampled residents (#s 1, 5, and 6) whose ABST evaluations were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 11/2025 with diagnoses including unspecified dementia, repeated falls, and rheumatoid arthritis. Review of the resident’s current service plan, dated 11/04/25, and current ABST evaluation, dated 11/11/25, indicated the following: * Resident 1’s service plan indicated the resident required caregiver assistance with showers once per week. In an interview on 11/19/25, Staff 11 (CG) stated it would take approximately 15 – 20 minutes to complete the shower with Resident 1; and * Resident 1’s ABST evaluation did not include the time required to provide the weekly shower assistance. The need to ensure resident ABST evaluations captured care time and care elements that staff were providing to each resident as outlined in each individual service plan was reviewed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 11/20/25. They acknowledged the findings. 2. Resident 6 was admitted to the facility in 07/2025 with diagnoses including neuropathy, chronic obstructive pulmonary disease, atherosclerotic heart disease of native coronary artery, and thrombocytopenia. The resident's record, including the current service plan, dated 11/14/25, and ABST data, was reviewed. The resident and staff were interviewed, and observations were made. The following areas were not reflective of the resident's current ADL assistance care time: * Providing treatments; * Administration of medication; * Personal hygiene; * Bathing; * Transferring; and The need to ensure resident ABST evaluations captured care time and care elements that staff were providing to each resident as outlined in each individual service plan was reviewed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 11/20/25 at 1:27 pm. They acknowledged the findings. 3. Resident 5 moved into the community in 07/2023 with diagnoses including dementia, cerebral atherosclerosis, and major depressive disorder. The resident's record, including the current service plan, dated 09/22/25, and ABST data, was reviewed. The resident and staff were interviewed, and observations were made. The following areas were not reflective of the resident's current ADL assistance care time: * Supervising, cueing, and supporting while eating; * Bathing; and * Dressing and undressing. The need to ensure resident ABST evaluations captured care time and care elements that staff were providing to each resident as outlined in each individual service plan was reviewed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 11/20/25 at 1:08 pm. They acknowledged the findings.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool- ABST time 1.Resident 1, 5 and 6 no longer reside at the community. 2. All resident service plans will be reviewed and compared to time accounted for care in the ABST, adjustments will be made accordingly. 3. ABST will be reviewed by Administrator or designee for each resident each week for 3 weeks and then quarterly, with additions or omission of services and with changes of condition 4. Administrator will monitor performance and make appropriate adjustments through the QAPI process for three months until substantial compliance is met and then quarterly thereafter.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by:

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to update and review the ABST evaluation for each resident before they moved in and whenever there was a significant change of condition for 2 of 6 sampled residents (#s 1 and 2) whose ABST evaluations were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 11/2025 with diagnoses including unspecified dementia, repeated falls, and rheumatoid arthritis. Review of the resident’s record indicated the following: * The resident’s ABST evaluation was created on 11/11/25, four days after the resident was admitted to the facility. The facility failed to develop the ABST evaluation before a resident moved into the facility as required. The need to ensure resident ABST evaluations are developed before a resident moved into the facility was reviewed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 11/20/25. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 06/2021 with diagnoses including repeated falls and rheumatoid arthritis. Review of the resident’s record indicated the following: * The resident’s ABST was last updated on 10/20/25 with a quarterly service plan evaluation. Per resident records, Resident 2 had a significant change of condition, effective 11/05/25, when s/he was admitted to hospice. The facility failed to update the ABST with a significant change of condition as required. The need to ensure resident ABST evaluations were updated with a significant change of condition was reviewed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 11/20/25. They acknowledged the findings.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool- Updates and Staffing Plan 1. Resident 1 no longer resides at community. Resident 2's care needs have been accuratley reflected in ABST for current time spent on care needs. 2. All resident service plans will be reviewed and compared to time accounted for care in the ABST, adjustments will be made accordingly. 3. ABST will be reviewed by Administrator or designee for each resident weekly for 3 weeks and then quarterly, with additions or omission of services and with changes of condition 4. Administrator will monitor performance and make appropriate adjustments through the QAPI process for three months until substantial compliance is met and then quarterly thereafter.

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

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents were instructed in fire and life safety procedures within 24 hours of admission as required by the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety records were reviewed on 11/17/25 at 2:45 pm with Staff 1 (Administrator) and Staff 10 (Lead Maintenance), and the following was identified: * There was no documented evidence residents were instructed on general fire and life safety procedures, evacuation methods, responsibilities, and designated meeting places inside or outside the building in the event of an actual fire within 24 hours of admission. On 11/20/25 at 12:50 pm, the need to ensure fire and life safety instruction was provided to each resident within 24 hours of admission as required by the OFC was discussed with Staff 1 and Staff 2 (Health Services Director). They acknowledged the findings.

OAR 411-054-0900 (5) Fire and Life Safety: Training for Residents 1. Residents have been re-instructed regarding facility's fire and life safety procedures. 2. All residents will be re-instructed regarding facility's fire and life safety at annual safety meeting and document in fire life saftey binder. New residents will be instructed at move-in and annually thereafter. Receipt of intructions will be documented. 3. The Administrator and or designee and Building Services Director and/or designee will audit fire life safety binder annually to ensure 100% of residents have been re-instructed on facility's fire and life safety training 4. Results of annual audit will be reported to the QAPI committee by the Building Services Director and/or designee.

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

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. This Rule is not met as evidenced by: Based on interview and observation, it was determined the facility failed to ensure its interior surfaces were clean and in good repair. Findings include, but are not limited to: The facility was toured with Staff 1 (Administrator) and Staff 11 (Lead Maintenance) on 11/19/2025 at 10:10 am. The following was noted: * Scuffs, chipped paint, and gouges were noted on doors, door frames, walls, corner pillars, and handrails throughout the facility, making some surfaces uncleanable. The door seal around apartment 337 was loose. * There was debris/dust noted on chair rails, baseboards, and wall and ceiling ventilation screens throughout the facility and on the windowsills in the Wing D stairway. * There was debris in many of the hallway ceiling lights on the first, second, and third floors and in the ceiling lights in the main lobby. * The following was observed in multiple resident laundry rooms: - Water damaged wall areas behind washing machines; - Several open wall areas behind washing machines; - Lint and debris behind the washing machines and dryers; - Brown water stains on ceiling panels; - Dirt and debris on several laundry room doors and on several garbage cans in the laundry rooms; and - There was plaster damage around the interior of the door frame of the laundry room on the second floor in Wing A. * On the second floor of Wing B the toilet and sink caulking in the common use restroom, across the hall from the Wing B sign, was deteriorated, causing the sink to not have a solid seal with the wall. There was debris along the perimeter of the bathroom floor. * In Rose’s Kitchen the following was observed: - There were spills/build-up on the bottom of the oven and oven door; - There was food debris on the sides, bottom, and top of the inside of the microwave; - Both refrigerators had dust on top of them; and - Both refrigerators had a black substance noted on the exterior of the refrigerator and freezer when the door was opened, and food debris was noted inside the refrigerator and freezer compartments. The need to ensure the facility’s interior surfaces were clean and in good repair was reviewed with Staff 1 and Staff 11 on 11/19/25 at 10:10 am. They acknowledged the findings.

OAR 411-054-0300 (4) (d-i) General Building: Doors, Walls, Cleanable 1. Uncleanable surfaces repaired, debris and dust cleared, laundry rooms were cleared of dust and debris, open areas patched and damaged ceiling tiles replaced. toilet and sink caulking repaired. Roses kitchen deep cleaned. 2. Building Services Director and Lead Maintinenence tech will complete and document weekly building walk throughs for general cleanliness and upkeep for 3 weeks and then quarterly. 3.Administrator or designee will review building services walk-throughs quarterly for compliance. 4. Administrator or designee will monitor performance and make appropriate adjustments through the QAPI process for three months until substantial compliance is met and then quarterly thereafter.

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. This Rule is not met as evidenced by: