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 observation, interview, and record review, it was determined the facility failed to ensure allegations of abuse were promptly investigated to rule out abuse and reported to the local SPD office when required, for 1 of 1 sampled resident (#4). Findings include, but are not limited to: Resident 4 was admitted to the facility in 03/2024 with diagnoses including anxiety. Observations of the resident, interviews with staff, and review of the resident's 08/01/24 service plan, 06/01/24 through 08/28/24 temporary service plans, progress notes, physician communications, and incident investigations were completed. The resident was able to communicate needs to staff and required full assistance of one to two staff for ADL care and transfers. The resident was forgetful, did not fully recognize his/her limitations, and had poor safety awareness. The resident preferred to remain in his/her apartment but did go outside to enjoy the sun periodically. The resident was no longer mobile and unable to feed himself/herself. The resident was additionally identified as having extremely fragile skin. Review of the resident's records showed the following: * A progress note dated 07/16/24, indicated the resident’s daughter reported the resident had expressed concerns to her. The resident told his/her daughter a male resident had “invited himself...” to the resident’s room on two different occasions and was “being rude and crude…” No investigation was documented regarding the allegations. There was no additional information within the progress notes about the incident, what occurred, how abuse and neglect was ruled out, the staff response to the resident incidents, or follow-up action related to the incidents. The facility was asked to report the incident to the local SPD office. A confirmation of the report was provided to the surveyor. The need to ensure all incidents were promptly investigated to rule out abuse was discussed with Staff 1 (ED), Staff 3 (Wellness Director/RN), and Staff 4 (Wellness Director Assistant/LPN) on 08/30/24. The staff acknowledged the findings.

C0231 1. Resident #4’s allegation for a visiting male resident was reported to SPD on 9/3/2024. Resident #4’s service plan will be updated to reflect current needs of resident, including interventions should male resident “invite himself” into her apartment in the future and resident preferences regarding visitors. 2. Abuse and neglect will be investigated timely, documentation of investigation and interventions will be completed timely following investigation. All suspected abuse and neglect or abuse/neglect that cannot be ruled out will be reported to SPD per reporting requirements. Documentation will be completed for all allegations of abuse per state regulations and company policies. Inservice to be conducted on 10/2/2024 to review required reporting guidelines for abuse and neglect. 3. Frequent review of resident documentation for identified or suspected abuse/neglect; New hire and annual training on abuse/neglect reporting 4. ED, WD, AWD

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:

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.(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 move- in 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 residents' needs, provided clear direction to staff regarding care and services, and were consistently implemented by staff for 4 of 6 sampled residents (#s 1, 2, 4, and 6) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 10/2008 with diagnoses including COPD. Observations of the resident, interviews with staff, and review of the service plan, dated 07/12/24, showed the service plan was not reflective of the resident's current care needs, was inconsistently implemented, and/or did not provide clear direction to staff in the following areas: * Skin picking, picking at sores; * Toileting assistance and incontinence care; * Wheelchair, footrests, and walker use; * Clothing changes, toileting in inappropriate areas, and disrobing; * Ambulation; * Elopement risk and potential exit-seeking; * Ability to make needs known and impaired cognition; and * Swallowing issues, coughing/choking risk, and staff intervention. The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (ED), Staff 3 (Wellness Director/RN), and Staff 4 (Wellness Director Assistant/LPN) on 08/30/24. The staff acknowledged the findings. 2. Resident 4 was admitted to the facility in 03/2024 with diagnoses including anxiety. Observations of the resident, interviews with staff, and review of the service plan, dated 08/01/24, showed the service plan was not reflective of the resident's current care needs, was inconsistently implemented, and/or did not provide clear direction to staff in the following areas: * One-person vs. two-person transfers; * Sleeping in the recliner and recliner controls/use; * Pain control and needs; * Cognitive impairment and directing his/her own care; * Self-transferring and poor safety awareness; * Toileting assistance and incontinence care; * Fall interventions including footwear, grip tape to floor, and anti-slip surface in chairs; and * Dining in his/her room vs. the dining room. The need to ensure resident service plans were reflective of current care needs, was consistently implemented, and provided direction to staff was discussed with Staff 1 (ED), Staff 3 (Wellness Director/RN), and Staff 4 (Wellness Director Assistant/LPN) on 08/30/24. The staff acknowledged the findings. 3. Resident 2 was admitted to the facility in 06/2024 with diagnoses including congestive heart failure, chronic kidney disease, and glaucoma. The resident’s current service plan, most recently updated on 08/29/24, progress notes from 06/15/24 through 08/26/24, and temporary service plans were reviewed. Interviews with staff and the resident were completed. The following was identified: * The resident experienced a fall 07/02/24, resulting in a hip fracture. S/he was sent out to the emergency room, admitted to the hospital, underwent surgery on his/her hip, went to a skilled nursing facility, and returned to the facility on 07/23/24. * On 08/07/24 Staff 3 (Wellness Director/RN) wrote a progress note about the resident “refusing ordered daily weights” and “a decreased appetite.” When Staff 3 spoke with the resident, s/he told Staff 3 they had “about” two protein shakes a day and tried to “eat at least half of the food” they were served. The resident’s service plan did not include information about his/her recent hip surgery or about s/he having protein shakes twice a day. The need for service plans to be reflective of residents’ current status and care needs was discussed with Staff 1 (ED) on 08/30/24. She acknowledged the findings. 4. Resident 6 was admitted to the facility in 04/2023 with diagnoses including congestive heart failure, rheumatoid arthritis, and asthma. The resident’s current service plan, most recently updated on 07/13/24, progress notes dated 05/28/24 through 08/28/24, and temporary service plans were reviewed. Interviews with staff and the resident were completed. The resident’s service plan was not reflective of the resident’s current status or care needs in the following areas: * Placement of bed; * Use of a bed cane; * Meal assistance required; * Use of oxygen and BIPAP/CPAP; and * Smoking. The need for service plans to be reflective of residents’ current status and care needs was discussed with Staff 1 (ED) on 08/30/24. She acknowledged the findings.

C260 1. Resident #1 will be assessed for skin integrity, toileting assistance and incontinence care, ambulation and assistive device use, need for dressing assistance, elopement risk including risk of exit seeking, ability to make needs know and impaired cognition, swallowing issues including risk of choking. Resident #1’s service plan will be updated to reflect current resident status based on above findings and including staff directions for identified risks. Resident #4 will be assessed for transfer assistance, ability to use recliner controls and where resident chooses to sleep, current pain and management of pain, cognitive impairment and ability to direct their care, toileting assistance and incontinent care, fall interventions for footwear, grip tape and anti slip surface in chair, where resident chooses to dine. Resident #4’s service plan will be updated to reflect resident current needs and include staff directions for anticipated risks. Resident #2 will be assessed for current care needs including history of weight loss, need for additional supplements, current appetite, history of fractures and surgeries. Resident #2’s service plan will be updated to reflect resident’s current needs, historical information and directions for staff for identified risks of weight loss. Resident #6 will be assessed for placement of bed and use of bed cane, need for meal assistance, use of oxygen/BiPAP/CPAP and smoking. Resident #6’s service plan will be updated to reflect the above findings. 2. Changes to resident’s service plan as identified through assessments or scheduled review will either be directly updated into the service plan or placed on temporary service plan and included with the current service plan. 3. Upon admit, within 30 days of admit, every 90-days and significant change in condition. 4. ED, WD, & AWD

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.(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 move- in 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 residents who had short-term changes of condition were evaluated, resident-specific instructions or interventions were developed and reviewed for effectiveness, and weekly progress documented until resolution for 1 of 6 sampled residents (#4) who experienced changes of condition. Findings include, but are not limited to: Resident 4 was admitted to the facility in 03/2024 with diagnoses including anxiety. The resident's 08/01/24 service plan,05/28/24 through 08/28/24 progress notes, incident investigations, temporary service plans, and physician communications were reviewed. a. The resident experienced multiple short-term changes without noted progress at least weekly until resolved and/or lacked resident-specific directions to staff in the following areas: * Skin tears; * Medication changes; * Allegation of resident altercation/abuse; * Bruises to hip and arm; and * Multiple falls. b. Incident investigations on 06/08/24, 06/09/24, and 07/02/24 indicated the resident had falls as a result of slipping from the recliner chair. The incident investigation on 07/02/24 indicated the resident had slipped out of his/her recliner many times, and the facility planned to discuss the safety of the lift chair with the resident’s family. Under the section “Discuss Interventions” it was noted “unsure if the lift chair is appropriate and safe for (the resident).” No other documentation or evaluation of the lift chair could be located. In an interview on 08/30/24, Staff 3 (Wellness Director/RN) was unsure if she had completed an assessment of the lift chair. Staff 3 stated they had tried additional non-slip options to the seat to attempt to prevent additional slips and falls. No evaluation or assessment of the safety of the lift chair or the effectiveness of the device was located. The need to ensure short-term changes of condition had documentation of weekly progress until resolution, interventions were re-evaluated for effectiveness, and provided clear, resident-specific directions to staff was discussed with Staff 1ED), Staff 3 (Wellness Director/RN), and Staff 4 (Wellness Director Assistant/LPN) on 08/30/24. The staff acknowledged the findings.

C0270 1.1. Resident 4 has been assessed for skin integrity, medications have been reviewed for changes or modifications, resident has been interviewed regarding allegations of abuse including asking resident if they feel safe in their environment, and resident’s fall history has been reviewed including current fall interventions. (a) Staff will implement temporary service plans with monitoring guidelines for any current change in condition that deviates from current service plan. Documentation of progress will occur weekly until resolved. (b) Resident #4’s recliner will be assessed for resident’s ability to safely use. Family and resident will be included in discussion for safe use of recliner and interventions for improved safety. New interventions for fall prevention and recliner use will be implemented as identified, and monitored for effectiveness. Effectiveness will be documented, effective interventions will be included in resident’s service plan with directions for staff. 2. All changes in condition will be timely assessed and monitored. Progress will be documented at minimum weekly. This will include follow up for effectiveness of any interventions put in place. Weekly monitoring will continue until resolve of change of condition. Resident’s service plan will be updated with staff directions for effective interventions. 3. Frequently for change of condition monitoring at 30-day and 90-day and significant change of condition review for service plan updates. 4.WD, AWD & ED

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 an RN assessment was completed in a timely manner and documented findings, resident status, and interventions made as a result of the assessment for 2 of 3 sampled residents (#s 1 and 6) who experienced significant changes of condition. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 10/2008 with diagnoses including COPD. Observations of the resident, interviews with staff, review of the service plan, dated 07/12/24, and 06/24/24 through 08/28/24 progress notes, physician communications, and weight records was completed. The resident required full assistance from staff for ADL care. The resident was able to eat independently with some reminders to chew slowly and swallow before taking additional bites. The resident was able to make some needs known but not consistently. Staff anticipated the resident’s needs whenever possible. Multiple observations of the resident between 08/28/24 and 08/30/24 showed the resident seated in the lobby of the facility with walker next to him/her or seated in a wheelchair. Meal observations showed s/he ate independently with reminders from staff and tablemates to chew slowly and swallow one bite at a time. The resident was provided with a mechanical soft diet and minced/ground meats with extra sauces. The resident was able to alternate food and fluids throughout the meal with minimal reminders. The resident would visit with those around him/her and participate in different activities offered in the lobby area. Weight records for 05/2024 through 08/2024 showed the following: * A 22-pound weight gain between 05/05/24 and 06/04/24, which constituted a 13.9% increase in one month. * A 13.1-pound loss between 07/08/24 and 08/09/24, which constituted a 7.26% weight loss in one month. The resident’s weight increased less than two pounds between 08/09/24 and 08/23/24. In interviews between 08/28/24 and 08/30/24, the resident indicated s/he had no concerns and had plenty to eat and drink. The resident was not sure if s/he could ask for alternate items or more to eat because s/ never had the need. In interviews between 08/28/24 and 08/30/24, Staff 11 and Staff 16 (CGs) indicated the resident required full assistance with ADL care but could eat on his/her own. The resident had swallowing precautions in place to eat slowly and swallow one bite before taking the next bite. The staff indicated the kitchen provided the resident’s special diet at each meal. The resident had mechanical soft items, and the meats were more of a ground-up texture, so no large chunks, and extra moisture. The staff indicated the resident had a good appetite and did well with his/her meals. In an interview on 08/30/24, Staff 3 (Wellness Director/RN) indicated she was aware of the weight changes and the physician was contacted. She could not locate a significant change assessment and was not sure why one was not completed. The facility failed to ensure an RN assessment was completed for the weight loss and gain which documented findings, resident status, and interventions made as a result of the assessment. The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made as a result of the assessment for all significant changes of condition was discussed with Staff 1 (ED) and Staff 3 (Wellness Director/RN) on 08/30/24. The staff acknowledged the findings. 2. Resident 6 was admitted to the facility in 04/2023 with diagnoses including congestive heart failure, rheumatoid arthritis, and asthma. The resident’s current service plan, most recently updated on 07/13/24, progress notes dated 05/28/24 through 08/28/24, and temporary service plans were reviewed. Interviews with staff and the resident were completed. The following was identified: Progress notes revealed the resident was on alert charting starting in 05/2024 related to his/her dentures being missing. In an interview with the resident on 08/30/24, s/he stated that losing his/her dentures had changed their life. S/he reported they were uncomfortable being around other people without their dentures. Because of this discomfort, the resident said s/he no longer ate meals in the dining room and only left their apartment at night when there were very few people in the common areas. A progress note dated 05/28/24 indicated the resident had experienced a significant change of condition related to “Missing dentures, missing glasses, open areas in mouth, pressure wounds to upper leg/low buttock, and left side of buttock.” The note was written by Staff 4 (Assistant Wellness Director/LPN). There was no documented follow-up by the RN to confirm Staff 4’s findings. The first documented assessment by the RN was dated 07/30/24. In an interview on 08/30/24, Staff 3 stated she had not completed a significant change of condition assessment for the resident’s missing dentures in 05/2024. The need for an RN to complete an assessment, which included findings, resident status, and interventions made as a result of the assessment, for all significant changes of condition was discussed with Staff 1 (ED) on 08/30/24. She acknowledged the findings.

C280 1. Resident #1 will be assessed by RN for significant weight loss/gain. Service plan will be updated to reflect current diet order/texture, eating ability including need for supplements and assistance, and additional interventions as identified for weight management. Identified significant changes will be assessed weekly until resolved with documented progress. Service plan will be updated and reviewed by RN to ensure that it acurately reflects resident’s current needs and staff directions for interventions of identified risks. Nursing will review with resident options for dining inculding alternate menu items to meet resident’s needs. Identified choking risk will be coordinated with third party for further assessment and orders on choking precautions or texture modifications. Resident #6 will be assessed by RN for significant weight loss, oral health, and skin integrity. All identified significant changes will be assessed at minimum weekly until resolved with documented progress. RN will review interventions for effectiveness and ensure service plan is updated with sucessfu interventions and staff directions. Resident #6’s service plan will be updated to reflect history of significant changes, interventions and directions for staff. 2. RN will participate in review of service plan interventions within 48 hours of all significant changes in condition. All significant changes in condition will be timely assessed by the RN. RN assessment will be documented and include appropriate interventions as identified to reduce risk. RN will review all temporary service plan and service plan updates for appropraite intervnetions and staff directions. 3. As indicated by significant change in condition, within 48 hours. 4. RN, AWD, ED

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 411-054-0037 (4)(5)(6)(a-b)(C) Acuity Based Staffing Tool: Frequency of 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 ensure the posted staffing plan was reflective of the staffing needs calculated by the Acuity-Based Staffing Tool (ABST) and the staffing levels exceeded the number of staff indicated by the ABST. Findings include, but are not limited to: The facility’s ABST entries, staff schedule, calculated staffing hours, and posted staffing plan were reviewed. The following was identified: * The facility’s ABST indicated that six to seven staff were needed for day and evening shifts, dependent on the day of the week; * The facility was staffing five to six staff on day and evening shifts, three to four caregivers and two medication technicians; * The ABST indicated two staff were needed for the night shift; * The facility was staffing three staff on the night shift, two caregivers and one medication technician; and * The posted staffing plan did not match the staffing plan the facility was using. The need to ensure the facility staffing plan and staff working on the floor exceeded the ABST staffing calculations and that the posted staffing plan matched the current staffing plan was discussed with Staff 1 on 08/30/24. She acknowledged the findings.

C0363 1. Posted staffing plan was reviewed and updated 9/27/2024. Additional staff have been hired for designated shifts needed. 2. Staffing plan will be updated with as there are any change in service plans, new move ins or move outs based of the ABST staffing tool used. 3. Staffing plan will be updated & posted regularly as ABST is indicated per amount required. 4. ED

OAR 411-054-0037 (4)(5)(6)(a-b)(C) Acuity Based Staffing Tool: Frequency of 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 (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 ensure all required components for fire drills conducted, were documented in accordance with the Oregon Fire Code. Findings include, but are not limited to: Fire and life safety records, reviewed between 03/2024 and 08/2024, showed fire drill documentation was lacking in the following areas: * The escape route used; * Problems encountered; * Evidence of alternate routes used; * Evacuation time-period needed; and * The number of occupants evacuated. The need to ensure all required components were addressed and documented for each fire drill, was discussed with Staff 1 (ED) and Staff 9 (Plant Operations) on 08/28/24 and 08/29/24. The staff acknowledged the findings.

C0420 1. Fire Life & Safety records were adjusted to include escape route used, problems encountered, alternate routes used, evacuation time period and number of residents evacuated. 2. Fire & Life Safety records were altered to include the escape route, any problems encountered, alternate routes, evacuation time period, and number of residents participated in evacuation. 3. Fire drills, Elopement drills will be conducted on a monthly basis and will alternate shifts 4. ED, Plant Operations 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 ensure unannounced fire drills included all required components. This is a repeat citation. Findings include, but are not limited to: On 02/26/25 review of facility fire drills, from 11/2024 through 02/2025 identified the facility lacked documented evidence of the following required components: * Location of the simulated fire origin; * Escape route used; * Problems encountered, comments related to residents who resisted or failed to participate in the drills; * Evacuation time period needed; and * The number of occupants evacuated. The need to ensure unannounced fire drills included all required components was discussed with Staff 1 (ED) on 02/26/25 at 5:32 pm. She acknowledged the findings

C 420 1) Fire Life and Safety records will include documentaton: location of fire, escape route used,any problems encountered, evacuation time period & number of occupants evacuated. 2) Training was conducted with Plants OPS on 3/10/2025 going over OAR 411-054-0090 regulations and details that need to be included in the records with every drill. We discussed all components of the drill and reached a clear understanding of what is expected. 3) Fire drills will be conducted every other month, alternating shifts. 4) ED & Plant Operations 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:

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 420.

See C420

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

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF 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) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF 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 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF 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 courtyard surfaces were maintained in good repair. Findings include, but are not limited to: Observations of facility pathways, patio, and seating areas on 08/28/24 and 08/29/24 identified the following: * Multiple drop-offs of 2-5 inches were noted along pathway edges around the perimeter of the facility and along the paths at exterior exit doors. * A large crack across the pathway near the exit closest to Room 108 was separating and lifting, which created a small lip. A small piece of the concrete was missing at the corner, as well. The need to ensure pathways around the facility were in good repair with no potential tripping hazards was discussed with Staff 1 (ED) on 08/29/24. She acknowledged the findings.

C610 1. Multiple Drop offs in back courtyard have been assessed and have been filled in along exterior pathways. 2. System will be monitored on a weekly bases to maintain pathway edges around perimeter. 1. Crack in sidewalk has be assessed. Edge has been painted, cones have been placed for tripping. 2. Pathways to be monitored on a weekly bases to ensue all seams are even, not broken or cracked. 3. Weekly walkthroughs of outside grounds premisis will be completed by Plant OPS to ensure there are no potential tripping hazards, and everything is in good repair. 4. ED, Plant OPS Director

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF 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) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF 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 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF 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:

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 observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. Findings include, but are not limited to: Observations of the facility on 08/28/24 and 08/29/24 showed the following areas in need of cleaning or repair: * Multiple walls, doors, baseboards, and door frames in the facility had scrapes, dings, chips, missing pieces of wood, or spills; * Numerous black/gray carpet stains, of various sizes, in the common areas and hallways on both floors; * First floor laundry room floor was separating at the seams. The washing machines had brown splatters on the top surfaces and debris in the edges of the machine lids and soap cups. One machine had scraped paint and rust on the interior lip of the lid; * Multiple dining room chairs and common area furniture had stains, spills, and/or debris on the seats or backs; * Benches in the Coca-Cola room had food spills and tears in the seats. Missing chunks of floor around the drain in the kitchen area with debris accumulation noted; * Large wall vents on the first floor had significant dust/cobweb accumulation on the slats; * Strong sour/soiled odor on the resident common patio. A fly-catching bag was overfilled with dead insects, approximately two to three inches thick; * Multiple ceiling light fixtures in the dining room had large amounts of debris and dead insects inside; * Rooms 216, 221, 225, 234, 235, and 236 had significant scrapes or dings across the lower portions of the doors; * Elevator walls had significant scrapes and gouges; * Large scrapes to the wall in the first and second floor laundry rooms; * Windowsills, windows, and wooden blinds in the dining room, common areas, and hallways had dust accumulation, dead insects, debris, or cobwebs. The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (ED) and Staff 9 (Plant Operations) on 08/28/24 and 08/29/24. The staff acknowledged the findings.

C0613 1. Walls Baseboards, door frames have been assessed by Plant OPS. Doors have been painted, door frames are being replaced, chips in paint or textire are being filled and painted. 2. Daily walk throughs of Building and reports made into TELS system to ensure that areas in need of repair are being completed in a timely manner. 1. Numerous carpet areas have been assessed by Plant OPS and have been steam cleaned to remove any stains. 2.Daily walk throughs of Building and reports into TELS system to ensure that any stains are steam cleaned or replaced ina timely manner. 1. First floor laundry room has been assessed for splatters and debris. Machine lids and soap dispense areas have been wiped down. Interior washing machine lid where rust was forming has been cleaned and painted. 2. Washing Machines have been added to nightly cleaning schedule to maintain cleanliness and sanitation. 1. Laundry room floor has been assessed for seams seperating and a bid for replacement/ repair of floors is in place. 2. Quarterly walkthroughs with Plant OPS to ensure floors are in good repair. 1. Coca Cola room was wiped down and is free of any spills & Debris. Flooring around drain is being looked at by local flooring vendor for repair. 2. Cocal cola room to be wiped down and cleaned after every activity and maintained on a weekly basis to ensure that all surface areas are clean and in good repair. 1. Dining room chairs have been wiped down and are free of debris, stains & spills 2. Kitchen Utility to walk through after every meal to ensure that chairs are clean prior to the next meal being served. 1. Large wall vents on first floor have been wipe down and are free/ clear of any dust & cobwebs. 2. Housekeeping to maintain weekly vent cleanings to prevent dust and conwebs from forming. 1. Fly catching bag has been removed 8/30/2024 from resident common area patio and replaced with electric trap with no odor/ smell. Trap to be maintained by Plant OPS weekly to prevent build-up. 1. All Celing and Lobby lights have been fixtures have been cleaned and are free of any insects as of 9/24/2024. 2. Ceiling fixtures will be maintained by local vendor quarterly or as needed to prevent build-up of insects and debris. 1. Apartments 216, 221, 225, 234, 235 & 236 have been assessed by Plant OPS. Doors have been painted and walls have been repaired on the lower portions. 2. Daily walk throughs will be conducted and placed into TELS system to ensure they are repaired and maintained in a timely manner. 1. Elevator walls have been assessed for significant gouges and scrapes and faceplates will be installed to prevent further damage. 2. Plants OPS to install skid plates and will do a monthly assessment of elevator walls to ensure in good repair. 1. Laundry room walls have been assessed by Plant OPS on the first & second floors for scrapes. Any/all scrapes will be filled in repaired & painted to ensure appearance. 2. Plant OPS to complete a walk through weekly of both laundry rooms to ensure walls are in good repair with no scrapes or dings. 1. Window sills in the dining room have been cleaned as of 9/1/2024. Blinds in the dining room and common areas have been assessed for dust and debris and are scheduled for a deep cleaning. 2. Windoe sills and blinds have been added to the NOC shift check list of cleaning duties and will be wiped down on a nightly basis. Blinds will be cleaned quarterly, or as needed to prevent any dust or debris build up.

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: