OAR 411-054-0025 (5) Facility Administration: Required Postings (5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following: (a) Facility license. (b) The name of the administrator or designee in charge. The designee in charge must be posted by shift or whenever the administrator is out of the facility. (c) The current facility staffing plan. (d) A copy of the most recent re-licensure survey, including all revisits and plans of correction as applicable. (e) The Ombudsman Notification Poster. (f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections. (g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted. (h) Other notices relevant to residents or visitors required by state or federal law. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure required postings were posted in a routinely accessible and conspicuous location for residents and visitors and were available for inspection at all times. Findings include, but are not limited to: The facility’s environment was toured on 09/09/26 at 10:45 am. The following items were not posted in an accessible and conspicuous location: * The name of the administrator or designee in charge for each shift; * Facility staffing plan; * Ombudsman poster; * Resident rights and protections, including the LGBTQIA2S+ rights and protections; and * The LGBTQIA2S+ nondiscrimination notice. The need to ensure the required postings were posted in a routinely accessible and conspicuous location to residents and visitors and were available for inspection at all times was discussed with Staff 2 (Residential Director) and Witness 1 (Consultant) on 09/10/26 at 12:14 pm. They acknowledged the findings.

1. All required postings have been updated and are posted in a conspicuous area (the kitchen). 2. The administrator will be reviewing administrator alerts to ensure that all updated postings are added to the required posting area. The staffing plan and survey will be updated as needed. 3. On a monthly basis, the administrator will view the required postings area to ensure all required postings are up and in good condition. 4. Facility administrator.

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. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to immediately notify the local Department office or the local AAA (Area Agency on Aging) of any incident of abuse or suspected abuse and promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse for 1 of 1 sampled resident (#1) reviewed for incidents of suspected abuse. Findings include, but are not limited to: Resident 1 was admitted to the facility in 02/2023 with diagnoses including traumatic brain injury. Resident 1’s clinical record, including charting notes dated 07/15/26 through 09/09/26, were reviewed, and the following was identified: * 08/10/26 – The resident reported to a Transitional Living Specialist that other staff members were “stealing food” from [him/her]. * 08/13/26 – Staff noted that Resident 1 “accused another staff member of stealing [his/her] food.” * 08/24/26 – Staff documented the resident stated that staff had lost “all” of his/her sweatpants. The resident's statements regarding theft represented possible incidents of financial exploitation which the facility was required to report to the local Department office or AAA as an incident of suspected abuse. There was no documented evidence the resident’s statements were reported to the local Department office or AAA or that the facility investigated the reports and took measures necessary to prevent the reoccurrence of abuse. The need to ensure incidents of suspected abuse were immediately reported to the local Department office or AAA and investigated to ensure further abuse did not occur was reviewed with Staff 1 (Associate ED), Staff 2 (Residential Director) and Witness 1 (Consultant) on 09/10/26 at 3:14 pm. They acknowledged the finding and no additional information was provided.

1. Facility will complete updated Abuse Reporting inservice. Will update resident Safety Plan and Behavior Support Plan to reflect that resident is likely to make allegations of theft and to include a protocol on investigating such claims every time. 2. Abuse Reporting inservice will be completed annually in addition to required trainings. Safety Plans and Behavior Support Plans will consistently include processes for follow up on allegations as appropriate. 3. This issue will be reviewed and discussed quarterly at Service Plan reviews. 4. Facility administrator.

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation Temporary rule language in effect until 02/05/2027 (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 interview and record review, it was determined the facility failed to ensure smoking status was evaluated for 1 of 1 sampled resident (#1) who chose to smoke. Findings include, but are not limited to: Resident 1 was admitted to the facility in 02/2023 with diagnoses including traumatic brain injury. The resident’s clinical record, dated 07/15/26 through 09/09/26, was reviewed and staff were interviewed. The following was identified: On 09/10/26 at 2:07 pm, Staff 3 (Transitional Living Specialist) identified that Resident 1 smoked cannabis. There was documentation in multiple charting notes and “General Event Reports” of the resident smoking cannabis and how smoking the substance affected his/her ability to function. There was no documented evidence the resident’s ability to safely smoke independently had been evaluated. The need to ensure a smoking evaluation was completed for residents who chose to smoke was discussed with Staff 1 (Associate ED), Staff 2 (Residential Director) and Witness 1 (Consultant) on 09/10/26 at 3:14 pm. They acknowledged the findings and no additional information was provided.

1. Facility RN will complete initial smoking evaluations for all residents who smoke by 10/31/26. 2. A smoking evaluation has been added to facility quarterly service planning processes and will be evaluated by facility leadership or RN on a quarterly basis or at admit of a new resident. 3. Quarterly. 4. Facility RN and Administrator.

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 resident service plans were reflective of the resident’s needs, completed quarterly, readily available to staff and provided clear direction regarding the delivery of services for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 11/2024 with diagnoses including traumatic brain injury, bipolar disorder, dysphagia (difficulty swallowing) and chronic obstructive pulmonary disease. The resident’s most recent service plan, dated 06/01/26, was reviewed, observations were made and interviews with the resident and care staff were conducted. The following was identified: a. Resident 2’s most recent service plan was dated 06/01/26. The service plan was not updated quarterly by 09/01/26. b. In an interview on 09/10/26 at 11:25 am, Staff 3 (Transitional Living Specialist) reported Resident 2 responded positively to very specific routines for getting to sleep, waking, showering and getting dressed. For example, to ensure Resident 2 stayed in the shower long enough to adequately bathe him/herself, Staff 3 and Resident 2 had agreed to play two Beach Boys songs on a tape player as a timer. Staff 3 reported Resident 2 had a history of getting day and night confused, so specific supports and interventions were developed to assist with sleeping and waking. Resident 2 was at risk for aspiration and had orders to eat only minced and moist food items, and only food items that were prepared to that consistency were to be stored in the resident’s refrigerator for him/her to access; unprepared foods were stored securely elsewhere. The resident’s progress notes indicated the resident repeatedly hid soiled clothing and briefs throughout the apartment; Staff 3 confirmed this behavior still occurred regularly. Resident 2’s service plan lacked information and did not provide clear direction in the following areas: * The resident had a history of confusing day and night; * Specific steps to follow when assisting the resident to get ready for sleep; * Specific steps to follow to assist the resident with waking for the day; * Specific steps to follow to ensure the resident spent enough time in the shower; * Specific steps for laying out clothing, including which clothing items Resident 2 could don independently and which items s/he needed assistance with; * Clear information and instructions regarding the resident’s behavior of hiding soiled clothing and briefs; and * Clear instructions for what food could be stored in Resident 2’s refrigerator and what food should be stored securely. The need to ensure Resident 2’s service plan was completed quarterly, reflective of the resident’s needs and provided clear direction regarding the delivery of services was reviewed with Staff 1 (Associate ED), Staff 2 (Residential Director) and Witness 1 (Consultant) on 09/10/26 at 3:45 pm. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 02/2023 with diagnoses including traumatic brain injury and insomnia. The resident’s most recent service plan, dated 04/01/24, and behavior support plan, dated 03/02/26, was reviewed, observations were made and interviews with the resident and care staff were conducted. The following was identified: a. Resident 1’s most recent service plan was dated 04/01/24, and the behavior support plan was dated 03/02/26. Neither had been updated quarterly. b. The resident’s service plan and behavior support plan was not readily available to staff. c. In an interview on 09/10/26 at 2:07 pm, Staff 3 (Transitional Living Specialist) reported Resident 1 responded positively to asking for his/her “help” when performing a task (e.g. changing his/her sheets, sweeping, “I’ll do this if you do that,” etc.). She verified the resident smoked cannabis and how it affected him/her while under the influence. Staff 3 reported how she helped Resident 1 to be as independent as possible with his/her ADLs. On 09/10/26 at 12:25 pm, Resident 1 was observed to be wearing a black, knee high, compression stocking on his/her left lower extremity. Multiple charting notes and “General Event Reports” documented times when the resident fell, which included while under the influence of cannabis. Staff documented intimacy between Resident 1 and his/her neighbor, mentioned “exercises” they were trying to assist the resident with, Resident 1 staying up all night or going to bed in the early morning hours, the ability to request PRN medications and refusing care. Resident 1’s service plan lacked information and did not provide clear direction to staff in the following areas: * Interventions to address task avoidance; * Compression socks for his/her left lower extremity; * Fall interventions; * Safety strategies for when the resident was under the influence of cannabis; * Where Resident 1’s home exercises were located and how staff assisted with the activity; * What aspects of ADLs the resident could perform independently and what staff needed to set up for Resident 1 to be as independent as possible; * Sleeping routines; * If the resident was able to self-direct PRN medications; * Interventions when Resident 1 refused care and approaches that minimized the resident’s refusals of care; and * An intimate relationship with a neighbor and what to monitor for (e.g., if the relationship became non-consensual). The need to ensure Resident 1’s service plan was completed quarterly, readily available to staff, reflective of the resident’s needs and provided clear direction regarding the delivery of services was reviewed with Staff 1 (Associate ED), Staff 2 (Residential Director) and Witness 1 (Consultant) on 09/10/26 at 3:14 pm. They acknowledged the findings.

1. All facility service plans will be updated to the current template and to include further detail on routines, preferences, and care to be provided by staff. A new service plan binder will be placed in the staff office ensuring service planning documents are all readily available for staff. 2. There is a new system in place to ensure quarterly updates are occuring during IDT meetings starting in the month of October. All staff will be retrained on service planning documents at the staff meeting on 10/08/26 and quarterly thereafter. 3. Quarterly or at change in condition. 4. Residential manager and 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. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to determine, document and communicate to staff what actions or interventions were needed for a resident following a short-term change of condition and failed to note weekly progress of the condition until resolved for 2 of 2 sampled residents (#s 1 and 2) with multiple changes of condition requiring monitoring. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 11/2024 with diagnoses including traumatic brain injury, bipolar disorder, dysphagia and chronic obstructive pulmonary disease. a. Review of the resident’s clinical record indicated the facility failed to determine, document and communicate to staff what actions or interventions were needed in response to the following short-term changes of condition and failed to note weekly progress of the condition until resolved: * 07/09/26 - Sore on bottom; * 07/11/26 - An emergency department visit for abdominal pain: * 07/17/26 - Attempting to exit a moving vehicle; * 07/17/26 - Resident-to-resident verbal altercation; and * 08/31/26 - The resident was not administered routine dosage of loperamide as prescribed. b. On 08/11/26, Resident 2 lost his/her balance and fell, sustaining abrasions to the elbow and back of head. The facility documented instructions for staff to monitor and document on the head abrasion; no instructions were provided for monitoring the elbow abrasion. There was no documented evidence facility staff documented on the status of the abrasions as instructed until the injuries were determined to have resolved. The need to ensure the facility had a system for responding to resident changes of condition was reviewed with Staff 1 (Associate ED), Staff 2 (Residential Director) and Witness 1 (Consultant) on 09/10/26 at 3:45 pm. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 02/2023 with diagnoses including traumatic brain injury, acid reflux and insomnia. The resident’s clinical record, dated 06/03/26 though 09/09/26, was reviewed. The following was identified: a. There was no documented evidence the facility determined, documented and communicated to staff what actions or interventions were needed in response to the following short-term changes of condition with weekly progress of the condition noted until resolution: * 06/05/26 - Witnessed, non-injury fall; * 06/10/26 - Witnessed fall in the shower with complaints of ankle pain; * 07/12/26 - Melatonin (used for sleep) was not administered; * 07/16/26 - Witnessed fall while trying to open a bottom drawer; * 08/01/26 through 08/06/26 - The facility administered incorrect bowel medication; * 08/12/26 – The resident slipped out of his/her manual wheelchair in the parking lot; * 08/13/26 - Unwitnessed fall out of his/her manual wheelchair while going up ramp without assistance; * 08/15/26 - The resident burned his/her hand while getting food out of the oven; * 08/17/26 - Docusate (used for bowel care) was not administered; * 08/21/26 – Complaints of arm pain; * 08/27/26 through 08/31/26 - Staff documented the resident had not had a bowel movement; * 09/02/26 - Furosemide (used to treat fluid retention) was not administered; and * 09/04/26 - Staff documented that Resident 1 "pointed out a pressure sore on [his/her] elbow from rubbing on [his/her] arm of [his/her] wheelchair." b. Staff documented Resident 1 refused medications on the following dates: * 06/03/26; * 06/17/26; and * 06/24/26 through 07/31/26. There was no documentation of which medications the resident refused. Resident 1 refused a 5:00 pm dose of pantoprazole (used to treat acid reflux) on the following dates: * 08/03/26 through 08/07/26; * 08/09/26 through 08/12/26; * 08/17/26 through 08/22/26; * 08/25/26; * 08/26/26; * 08/28/26; * 08/30/26; and * 09/01/26. There was no documented evidence the facility determined, documented and communicated to staff what actions or interventions were needed in response to the resident refusing the medications and no documented evidence that weekly progress was noted through resolution. c. The facility documented not administering medications on the following dates: * 06/18/26; * 07/18/26; and * 07/24/26. There was no documentation of which medications the facility had not administered. There was no documented evidence the facility determined, documented and communicated to staff what actions or interventions were needed in response to the resident not receiving the medications and no documented evidence that weekly progress was noted through resolution. The need to ensure the facility determined, documented and communicated to staff what actions or interventions were needed in response to the resident experiencing short term changes of condition was reviewed with Staff 1 (Associate ED), Staff 2 (Residential Director) and Witness 1 (Consultant) on 09/10/26 at 3:14 pm. They acknowledged the findings.

1. Updates will be made to the Change of Condition and Enhanced Monitoring policies and procedures which will then be retrained with all facility staff. Updated documentation templates will be developed to ensure staff are all able to document appropriately. 2. The full policy and procedure for Enhanced Monitoring and Change in Condition has been updated and will be monitored on an ongoing basis. 3. Daily related to monitoring for changes in condition and weekly by way of audit. 4. The full residential leadership team - manager, director, and supervisors.

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 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to 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. Findings include, but are not limited to: In an interview on 09/10/26 at 12:50 pm, Witness 1 (Consultant) stated she did not think the facility had designated an Infection Control Specialist but would check with Staff 1 (Associate ED). At approximately 12:55 pm, Staff 1 stated the facility had not identified an Infection Control Specialist. No further documentation was provided. The need to ensure the facility designated an individual to be the facility’s Infection Control Specialist was reviewed with Staff 1, Staff 2 (Residential Director) and Witness 1 on 09/10/26 at 3:45 pm. They acknowledged the lack of a designated Infection Control Specialist.

1. Residential Program Director, Stephen Grunig, has been identified as the Infectious Disease Specialist and has completed his OCP training as of 09/30/26. 2. This is a one time training requirement. The requirement to have a designated Infectious Disease Specialist has been added to our Infection Control policy to ensure continuity if the director leaves the agency. 3. This is a one time training that will be completed by 10/31/26. The administrator will review this on an annual basis as part of their annual audit of training requirements. 4. Program Director.

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. This Rule is not met as evidenced by: Based on 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 that the facility was responsible to administer for 2 of 2 sampled residents (#s 1 and 2) whose orders and MAR were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 11/2024 with diagnoses including traumatic brain injury, bipolar disorder, dysphagia (difficulty swallowing) and chronic obstructive pulmonary disease. Review of Resident 2’s signed physician orders, provided by the facility, and the resident’s 09/01/26 through 09/09/26 MAR/TAR indicated the following: a. The following orders were not included on the MAR and were not being administered as prescribed: * Lidocaine 5% patch – apply two patches daily; * Propranolol hydrochloride 20 mg tablet – one tablet TID; * Albuterol 2.5mg/3 ml nebulizer inhalant – inhale three ml every four hours; and * Acetaminophen 500 mg tablet – one tablet every eight hours as needed. b. The facility did not have written, signed prescriber orders in the resident’s record for the following medications the MAR indicated the facility was administering: * Acetaminophen 500 mg tablet – two tablets TID; * Ferrous sulfide 325 mg tablet – one tablet every other day; * Vitamin B1 100 mg tablet – one tablet daily; * Albuterol 2.5mg/3 ml nebulizer inhalant – inhale three ml every four hours as needed; * Ibuprofen 200 mg tablet – two tablets every eight hours as needed; and * Olanzapine 2.5 mg tablet – one tablet every eight hours as needed. c. Progress notes beginning on 07/09/26 indicated the staff identified a sore on the resident’s “upper rear crevice” and began applying barrier cream to the area. There were no written, signed orders for barrier cream and instructions for the treatment. The need to ensure orders were carried out as prescribed and written, signed physician orders were documented in the resident's facility record was reviewed with Staff 1 (Associate ED), Staff 2 (Residential Director) and Witness 1 (Consultant) on 09/10/26 at 3:45 pm. They acknowledged the issues with the physician orders. 2. Resident 1 was admitted to the facility in 02/2023 with diagnoses including traumatic brain injury with mild cognitive impairment, major depressive disorder, insomnia, diabetes and unspecified urinary incontinence. A review of the resident’s clinical record, dated 06/03/26 through 09/09/26, indicated the following: a. Medications were not administered as prescribed to Resident 1 per charting notes, dated 07/12/26 through 07/24/26, and per the 08/01/26 through 09/10/26 MARs on the following dates: * 07/12/26 - Melatonin (used for sleep); * 07/18/26 - Resident 1 "missed [his/her] [2:00 pm medication]" due to staff assisting the resident to use the restroom. Staff did not document which medication was “missed”; * 07/24/26 - Staff documented "Night [medications] were not administered" due to "it being [past his/her medication] window." Staff did not document which night medications were not administered; * 08/06/26 - Divalproex (used for mental health, mood conditions); * 08/17/26 - Docusate (used to prevent constipation); * 08/18/26 - Divalproex and docusate; * 08/19/26 - Docusate; * 08/24/26 - Divalproex; * 08/31/26 - Divalproex, docusate, lisinopril (used to protect heart and kidneys), melatonin (used for sleep), metformin (used to treat diabetes), quetiapine (used for mood), oxybutynin (used for incontinence), and vitamin D (used for a supplement); and * 09/02/26 - Furosemide (used for pedal edema). b. On 08/31/26, staff documented the resident had not had a bowel movement during his/her shift and the last documented bowel movement was on 08/27/26. Resident 1 had the following PRN medications to treat constipation: * Fleet enema - insert one bottle rectally one time for one does after three days without a bowel movement; and * Polyethylene glycol powder - if no bowel movement in three days, administer on the morning of the fourth day. There was no documented evidence the PRN fleet enema was administered on 08/30/26 or the PRN polyethylene glycol powder was administered on 08/31/26. Resident 1's MAR directed staff to call the physician "on the morning of day [five if] only a small or no bowel elimination when morning of day [four] polyglycol is not effective." On 09/06/26, staff documented the resident did not have a bowel movement on his/her shift and she contacted the facility RN. There was no documented evidence the facility contacted the resident's physician on 09/01/26, which was day five of no documented evidence of a bowel movement. c. On 09/04/26, staff documented that Resident 1 "pointed out a pressure sore on [his/her] elbow from rubbing on [his/her] arm of [his/her] wheelchair." Per the documentation, staff applied "Neosporin” (a topical ointment). The treatment was not transcribed on the resident's MAR nor was there documented evidence the facility had an order to administer the treatment. d. There was no documented evidence that written, signed physician or other legally recognized practitioner orders were in Resident 1’s facility record for the medications and treatments that the facility was responsible to administer. The need to ensure orders were carried out as prescribed and written, signed physician orders were documented in the resident's facility record was reviewed with Staff 1 (Associate ED), Staff 2 (Residential Director) and Witness 1 (Consultant) on 09/10/26 at 3:14 pm. They acknowledged the findings.

1. Complete and accurate orders are being obtained from all prescribing physicians to ensure that medication orders and MARs are all complete and accurate. These orders will all be on file both electronically in the Therap system as well as in paper form in the residents' Medical Binders. Medication retraining has occurred and will continue to be a routine topic in staff meetings to ensure documentation is accurate (missed medication reasons); no medications are given without orders; and that the 6 Rights of Medication Administration are always checked to ensure accuracy of both MARs and Orders. Resident specific protocols for certain PRNs, such as bowel regimens, will be updated and retrained. The facility nurse has done thorough medication room audits and removed any and all medications that do not have current, corresponding orders. 2. Semi-annual medication order reviews will be completed with all prescribers beginning in October. This will happen on a cycle of every other quarterly service plan update. Medication retraining topics have been added to monthly staff meeting inservices. A monthly Med and MAR audit has begun with the facility nurse starting in October. 3. Weekly via MAR and Progress Note reviews done by supervisors; monthly via nurse's MAR and Med audits; semi-annually via physician order reconciliation. 4. Facility nurse and all residential leadership (supervisors, manager, and director).

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to keep an accurate medication administration record (MAR) of all medications, including over-the-counter medications, that were ordered by a legally recognized prescriber and were administered by the facility for 2 of 2 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 11/2024 with diagnoses including traumatic brain injury, bipolar disorder, dysphagia (difficulty swallowing) and chronic obstructive pulmonary disease. Review of Resident 2’s 08/01/26 through 09/09/26 MAR/TAR indicated the following inaccuracies: a. The following medications did not include a reason for use: * Benztropine; * Gabapentin (routine dosage); * Melatonin; * Omeprazole; * Trazodone; * Vitamin B1; * Albuterol inhaler; and * Ketoconazole topical cream did not provide instructions for where the cream was to be applied. b. There were multiple blank entries on the 08/2026 MAR that lacked documentation of whether the medication was administered as prescribed or not. There was no additional explanation of the blank entries in the progress notes that corresponded to the dates of the blank entries. In an interview on 09/10/26 at 2:25 pm, Witness 1 (Consultant) stated there was no further documentation on the MAR explaining the circumstances of the blank entries. The need to ensure resident MARs were accurate was reviewed with Staff 1 (Associate ED), Staff 2 (Residential Director) and Witness 1 on 09/10/26 at 3:45 pm. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 02/2023 with diagnoses including traumatic brain injury with mild cognitive impairment, major depressive disorder, insomnia, diabetes and unspecified urinary incontinence. A review of the resident’s 08/01/26 through 09/09/26 MAR indicated the following inaccuracies: a. There were blank entries relating to the facility administering Resident 1’s medications on the following dates: * 08/06/26 - Divalproex (used for mental health, mood conditions), lisinopril (used to protect heart and kidneys), melatonin (used for sleep), metformin (used to treat diabetes), oxybutynin (used for urine flow and incontinence), quetiapine (used to improve mood), and vitamin D (used as a supplement); * 08/14/26 – Pantoprazole (used to treat acid reflux); * 08/23/26 – Divalproex; * 08/29/26 – Pantoprazole and divalproex; and * 08/31/26 – Pantoprazole. The 08/2026 MAR lacked documentation if the medication was administered as prescribed. b. Staff documented in a charting note on 09/01/26, the resident "had missed [his/her medications] due to improv," an activity Resident 1 attended in the community. However, staff initialed on the 09/2026 MAR that all medications had been administered on 09/01/26. c. There were no resident-specific instructions for multiple PRN pain medications for when to administer each medication. The need to ensure resident MARs were accurate was reviewed with Staff 1 (Associate ED), Staff 2 (Residential Director) and Witness 1 (Consultant) on 09/10/26 at 3:14 pm. They acknowledged the findings, and no additional information was provided.

1. Daily MAR audits are being completed by supervisors which will catch all "holes" in MAR documentation. Medication retraining has occurred and will continue via monthly inservices, this will address issues related to incorrect documentation. See details in C0303 for updates being made to orders and MARs - these updates will include ensuring indications are completed. Facility nurse will work directly with prescribers to ensure resident specific parameters are entered into the MAR for all PRNs. 2. There has been a new system of daily MAR audits enacted as of 09/28/26. There is also a new Med and MAR audit being done by the facility nurse which will address incomplete or unclear orders including parameters for PRNs. 3. Daily and monthly. 4. Facility nurse and supervisors.

OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to evaluate residents who chose to self-administer their medications at least quarterly to assure their ability to safely self-administer medications and ensure residents had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications for 1 of 1 sampled resident (#3) who self-administered his/her medications. Findings include, but are not limited to: Resident 3 was admitted to the facility in 07/2022 with diagnoses including traumatic brain injury. During the acuity interview, conducted on 09/09/26 at approximately 9:30 am, Staff 1 (Associate ED) and Staff 5 (Transitional Living Specialist) stated Resident 3 self-administered his/her medications. On 09/10/26 at 1:51 pm, the surveyor asked for an evaluation of Resident 3’s ability to safely self-administer his/her medications. Staff 1 and Witness 1 (Consultant) stated no evaluation had been completed. On 09/10/26, Witness 1 stated there was no order in Resident 3’s record to self-administer his/her medications. The need to ensure the facility evaluated residents who chose to self-administer their medications at least quarterly, and residents had a physician's written order of approval for self-administration of prescription medications was reviewed with Staff 1, Staff 2 (Residential Director) and Witness 1 on 09/10/26 at 3:45 pm. They acknowledged the findings.

1. A self-administration evaluation has been developed and will be completed by the facility RN or PCP for all residents who self-administer and quarterly thereafter. For residents who refuse to participate in this process or refuse to comply with getting orders from their physician, this will be thoroughly documented in their Safety Plan and on all self-administration evaluations. 2. All evaluations are completed quarterly by the facility RN and reviewed at quarterly IDTs. 3. Quarterly during IDTs. 4. RN and Program Director.

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure medications that were administered PRN that were given to treat a resident's behavior had written, resident-specific parameters and the PRN medications were used only after documented, non-pharmacological interventions were tried with ineffective results for 1 of 1 sampled resident (#2) who was prescribed a PRN psychotropic medication. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 11/2024 with diagnoses including traumatic brain injury, bipolar disorder, dysphagia (difficulty swallowing) and chronic obstructive pulmonary disease. Resident 2 was prescribed olanzapine 2.5 mg tablet – one tablet as needed for agitation. Review of Resident 2’s MAR and progress notes from 08/01/26 through 09/09/26 indicated the following: * The MAR lacked resident-specific parameters that described how Resident 2 exhibited “agitation.” * Resident 2 was administered the PRN olanzapine on 08/09/26. * There was no documented evidence non-pharmacological interventions had been tried with ineffective results prior to administering the medication on 08/09/26. The need to ensure PRN psychotropic medications included resident-specific parameters and were administered only after documented non-pharmacological interventions had been tried with ineffective results was reviewed with Witness 1 (Consultant) on 09/10/26 at 1:51 pm, and with Staff 1 (Associate ED), Staff 2 (Residential Director) and Witness 1 on 09/10/26 at 3:45 pm. They acknowledged the findings.

1. Psychotropic PRNs will all be reviewed by the facility nurse who will then update MARs to reflect non-pharm. interventions and clear parameters on when to administer. All Behavior Support Plans will also be updated to reflect psychotropic PRNs. All staff will be retrained to ensure non-pharm. interventions are attempted and documented prior to administering the PRN. 2. The Psychotropic PRN policy and procedure will be reviewed and updated. Psychotropics will be added as a topic to be reviewed at IDT meetings. 3. Quarterly at IDTs. 4. Residential manager/director and facility nurse.

OAR 411-054-0037 (1a)(2) Acuity Based Staffing Tool - Elements (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING. Facilities must select and implement a Department-approved Acuity-Based Staffing Tool (ABST) for determining appropriate staffing levels. Individual resident needs and care elements must be the primary consideration when developing and maintaining an ABST. Regardless of the ABST adopted, all requirements set forth in this rule and OAR 411-054-0034 (Resident Move-in Evaluation) must be met. Facilities shall: (a) Select and implement the Department’s developed ABST or submit a proprietary ABST to the Department for approval as outlined in paragraph (2) of this rule. (2) PROPRIETARY ABST. A facility that chooses to use a proprietary ABST must implement a Department-approved ABST that meets this rule. (a) REQUIRED ELEMENTS. The proprietary ABST the facility adopts must meet the following requirements: (A) Facilities can group or combine ABST care elements in their ABST reports, however each resident’s ABST evaluation must individually address and document all ABST care elements outlined in paragraph (3) of this rule. (B) When calculating total time, the ABST must include the care elements for each resident and staff time needed to complete each individual care element. (C) Ensure the ABST can produce a report that identifies all residents currently residing in the facility, the care elements for each of the residents, and the staff time required to complete the care elements for each resident. (D) ABST total time must present in minutes per shift, per day. If the proprietary ABST does not have this functionality, at a minimum the ABST total time must present in daily minutes. If a Proprietary ABST presents total time in daily minutes the facility’s ABST policy must describe how staffing per shift is determined. (E) Identify the date the resident’s ABST evaluation was last completed. (F) If applicable, determine ABST time for both residents on a Specific Needs Contract and residents not on a Specific Needs Contract to build posted staffing plans as outlined in this rule. (b) PROPRIETARY ABST REVIEW REQUEST. If a facility proposes to use a proprietary ABST, the facility must submit the Proprietary ABST ODHS Review Request form (se528132), including but not limited to the following: (A) Facilities who want to implement or switch to a proprietary ABST must submit Proprietary ABST ODHS Review Request form (se528132) prior to implementation. (B) Sample ABST report displaying the ABST care elements, and the staff time needed to complete the displayed care elements, with a total time in minutes shown per shift, per day. If the proprietary ABST only provides total time in daily minutes, the facility’s ABST policy must describe how staffing per shift is determined. (C) The facility’s ABST policy required under OAR 411-054- 0025(7)(i). (c) ABST SUMMARY STATEMENT. If the proprietary review request is approved, a facility must develop and maintain an ABST Summary Statement that meets the requirements, as outlined in the Proprietary ABST ODHS Review Request form (se528132). This includes providing a general guide explaining how the ABST functions. The summary statement must be available upon request by the Department. (d) DEPARTMENT REVIEW OF PROPOSED PROPRIETARY ABST REQUEST. The Department will review and either approve or deny the facility’s proprietary ABST. The Department may request additional documentation, potentially including a virtual demonstration, to make the determination. If the ABST is deemed to not meet this rule, the Department may deny or rescind approval at any time. The Department shall provide the facility with a written explanation of the reasons for the denial or decision to rescind approval. If a facility appeals a decision to rescind, the facility may continue to use the facility’s existing proprietary ABST until a final order has been issued. (e) APPEALS PROCESS. The Department will determine whether to approve or deny the request. If the proprietary ABST is denied or rescinded, the facility is entitled to a contested case hearing pursuant to ORS chapter 183. Prior to a contested case hearing, the facility may request an informal conference. (f) ANNUAL STATEMENT. Once approved, the facility must provide the Department an annual statement attesting no substantive changes have occurred to the design of the facility’s proprietary ABST that impacts its functionality. The facility must submit statements to the Department every year, between January 1 and March 31. (g) If the facility makes substantive changes to the proprietary ABST design, and if those changes impact ABST functionality making the prior submitted information inaccurate or invalid, then the facility must re-submit to the Department the Proprietary ABST ODHS Review Request Form (se528132) as described in this rule for review prior to implementing the new or revised ABST. (3) ABST CARE ELEMENTS. The required ABST care elements include activities of daily living and other tasks related to resident care and services, as outlined in OAR 411-054-0030, 411-054-0034, and 411-057- 0160. If any individual care element requires more than one staff, additional time must be accounted for as described in OAR 411-054-0070(1). The ABST must individually address and document the care time required to complete each of the following individual ABST care elements: (a) Personal hygiene. (b) Grooming. (c) Dressing and undressing. (d) Toileting, bowel, and bladder management. (e) Bathing. (f) Transfers. (g) Repositioning. (h) Ambulation. (i) Supervising, cueing, or supporting while eating. (j) Medication administration. (k) Providing non-drug interventions for pain management. (l) Providing treatments. (m) Cueing or redirecting due to cognitive impairment or dementia. (n) Ensuring non-drug interventions for behaviors. (o) Assisting with leisure activities, assist with social and recreational activities. (p) Monitoring physical conditions or symptoms. (q) Monitoring behavioral conditions or symptoms. (r) Assisting with communication, assistive devices for hearing, vision, and speech. (s) Responding to call lights. (t) Safety checks, fall prevention (u) Completing resident specific housekeeping or laundry services performed by care staff. (v) Providing additional care services. If additional services are not provided, this element can be omitted. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to select and implement a Department-approved acuity-based staffing tool (ABST) for determining appropriate staffing levels. Findings include, but are not limited to: In an interview on 09/09/26 at 12:45 pm, Witness 1 (Consultant) stated the facility had not implemented an ABST. Review of the ODHS ABST on 09/09/26 indicated no data had been entered into the facility’s ABST record. The need to ensure the facility selected and implemented an ABST was reviewed with Staff 1 (Associate ED), Staff 2 (Residential Director) and Witness 1 on 09/10/26 at 3:45 pm. They acknowledged the lack of an ABST.

1. The ODHS approved, ABST was completed on 09/11/26. 2. Based on this IIC being staffed based on a Specialized Living contract rather than acuity, this is a one time action with no follow up needed. The administrator is aware of the ABST process and will be responsible to update upon admit/discharge of any residents. 3. Upon admit or discharge or any resident. 4. Facility Administrator.

OAR 411-054-0070 (5, 9-10) Training Within 30 Days of Hire ? Direct Care Staff Temporary rule language in effect until 02/05/2027 (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible for verifying 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. (b) Exempt from this training requirement are contractors who contract directly with the resident or the resident’s representative, and contractors who do not generally provide services or supports directly to residents, including, but not limited to, contractors for landscaping, pest control, deliveries and building repairs. (c) By December 31, 2024, facilities shall ensure that all contracts entered into with entities described in paragraph (a) of this section shall include language requiring contractors provide Department-approved LGBTQIA2S+ training to their employees within 12 months of entering into the contract with the facility and every two years thereafter. (d) For existing contracts in effect January 1, 2025, facilities shall require the contractor provide Department-approved LGBTQIA2s+ training to employees by December 31, 2025, and every two years thereafter. (e) For new contracts created after January 1, 2025, facilities shall require contractors provide the Department-approved LGBTQIA2S+ training to employees within 12 months of entering into the contract with the facility, and every two years thereafter. (f) Facilities must inform contractors that the cost of all LGBTQIA2S+ trainings for contracted employees shall be paid by the contractor. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to verify 2 of 2 newly hired direct care staff (#s 5 and 6) had demonstrated competency in all assigned duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 09/10/26 at 1:40 pm. The following was identified: There was no documented evidence Staff 5 (Transition Living Specialist), hired 04/06/26, and Staff 6 (Transition Living Specialist), hired 08/10/26, had demonstrated competency within 30 days of hire in 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; * Conditions that require assessment, treatment, observation and reporting; and * Other duties as applicable (medication pass, treatments). The need to verify direct care staff demonstrated competency in all assigned duties within 30 days of hire was reviewed with Staff 1 (Associate ED), Staff 2 (Residential Director) and Witness 1 (Consultant) on 09/10/26 at 3:14 pm. They acknowledged the findings.

1. Core Competency checklists have been developed and all staff will be retrained by 10/31/26. 2. The new hire training and annual retraining processes will be updated to reflect updated Core Competency checklists and will be audited routinely. 3. Quarterly or at any time there is a new hire. 4. Program Director.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to conduct and record unannounced fire drills according to the Oregon Fire Code (OFC) every other month at different times of the day, evening, and night shifts and provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to: a. In an interview on 09/09/26 at 12:45 pm, Witness 1 (Consultant) stated the facility had not been conducting fire drills as required. Review of the facility fire drill records indicated the last fire drill was conducted in 01/2026. b. In a follow-up interview on 09/10/26 at 12:50 pm, Witness 1 stated the facility had provided training on maintaining safe resident apartments and techniques for supervising residents in the community in the August and September 2026 facility all-staff meetings, but that the facility had not documented the content of the training. No additional documentation was provided. The need to ensure the facility conducted and documented fire drills every other month and provided fire and life safety instruction to staff on alternate months was reviewed with Staff 1 (Associate ED), Staff 2 (Residential Director) and Witness 1 on 09/10/26 at 3;45 pm. They acknowledged the findings.

1. Staff will run fire drills and document them appropriately every month. These will be led by supervisors following training from director. Every other month, beginning in November 2026, residential leadership will include a section on Fire and Life Safety at monthly staff meetings. 2. A monthly reminder will be placed in shared Outlook and Teams calendars to ensure a Fire Drill occurs once per month at alternating times of day. Documentation of drills will be saved in paper form in the Emergency Procedure binder in the manager's office. Staff trainings on Fire and Life Safety will be worked into staff meetings as a recurring agenda item beginning in November 2026 with a reminder placed on the training audit spreadsheet. 3. Monthly - this will be reviewed monthly by supervisors and the administrator. 4. Program Director

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 re-instruct each resident at least annually in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. Findings include, but are not limited to: In an interview on 09/10/26 at 12:50 pm, Witness 1 (Consultant) stated the facility had not implemented a process for re-instructing its current residents in general fire and life safety procedures annually. No documentation of instruction was provided. The need to ensure the facility implemented a process to re-instruct residents in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building in the event of an actual fire was reviewed with Staff 1 (Associate ED), Staff 2 (Residential Director) and Witness 1 on 09/10/26 at 3:45 pm. They acknowledged the findings.

1. Starting in October, we will complete annual resident training sessions on Fire and Life Safety. The training will include details on evacuation, rally points in fire safe areas outside of the facility, general safety, and facility specific safety elements including but not limited to review of the emergency preparedness plan. 2. An annual reminder will be placed on shared Outlook and Teams calendars to ensure annual resident trainings occur. Documentation of these trainings will be saved in paper form in the Emergency Procedure binder in the manager's office. 3. These documents will be viewed monthly when the fire drills are completed to ensure they are never out of date. 4. Program Director.

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses to the RCF common-use areas, entrance and exit ways were made of hard, smooth material and maintained in good repair, took measures to prevent the entry of insects, grounds were kept orderly and were free of litter, and refuse and maintenance equipment was properly stored. Findings include, but are not limited to: The facility’s exterior environment was toured on 09/09/26 at 10:45 am, and the following was identified: a. The following exterior pathways and accesses to the RCF common-use areas, entrance and exit ways were not made of hard, smooth material and/or were not maintained in good repair: * The facility’s parking lot was observed to have cracks, deep grooves and missing concrete; and * There was an approximately four-inch deep by five-inch-wide drop-off around a concrete slab located at the bottom of stairs that led from a resident’s back deck. There were multiple charting notes reflecting residents using the parking lot to access an alley. On 09/10/26 at 12:14 pm, Staff 2 (Residential Director) confirmed residents had accessed the back outdoor area. b. There were gaps and holes large enough to allow the entry of insects observed in a resident’s backdoor screen. c. The following areas were not kept orderly and/or had litter and refuse observed: * The grounds by a resident’s back deck and a storage shed were overgrown with weeds, and plant debris was piled up in an approximately six feet by four feet shallowed-out area; * An over-flowing garbage bag, an empty soda can, potted dead plants, a five-pound hand-held weight, window screen, mop and a baking sheet were observed on a resident’s back deck; * Wooden benches on the back deck had splinters, and some of the wooden post caps were loose; * Debris and refuse were located on both sides and in the back of a storage shed; and * An approximately three feet by four feet piece of glass was leaning against the side of the building where the offices were located, between the back door and parking lot. d. Ladders and maintenance equipment were being stored in the facility’s parking lot. The need to ensure all exterior pathways and accesses to common-use areas, entrance and exit ways were made of hard, smooth material and maintained in good repair, the facility took measures to prevent the entry of insects, grounds were kept orderly and were free of litter and refuse and maintenance equipment was properly stored was discussed with Staff 2 and Witness 1 (Consultant) on 09/10/26 at 12:14 pm. They acknowledged the findings.

1. Parking lot concrete - on 10/05-10/06, new asphalt will be poured for the full parking lot 4"x5" drop off around stairs from deck - full deck and surrounding to be replaced by external contractor to include filling of holes in surrounding Holes in screen - screen will be replaced by internal maintenance team. Back deck and storage shed overgrown and plant debris - landscaping and debris removal to be completed by external contractor. Trash and dead plants on back deck - full deck and surrounding to be replaced by external contractor; cleanup to happen by care staff until deck replacement occurs. Deck splintering and loose caps - full deck and surrounding to be replaced by external contractor Debris and refuse near shed - junk removal contractor to remove all trash and debris; internal maintenance team will remove all building equipment. Glass leaning against building - this is in fact fiberglass that protects the basement window wells. This will be replaced by more sightly window well covers. Ladders and equipment - all ladders and maintenance equipment will be removed or placed in the garage by the internal maintenance team. 2. We will be enacting a monthly environmental safety walkthrough to be completed by supervisors and reported up to the director for follow up. 3. Monthly by environmental walkthroughs and annually by a full environmental audit done by the director. 4. Facility supervisors and director.