OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure resident move-in evaluations addressed all required elements for 1 of 1 sampled resident (#1) whose evaluations were reviewed. Findings include, but are not limited to: Resident 1 was admitted to the facility in 08/2024 with diagnoses including a suprapubic catheter and chronic pain. The resident’s move-in evaluation dated 08/09/24 was reviewed and lacked the following required elements: * Customary routines including sleeping, eating, and bathing; * Physical health status including list of current diagnosis; * Mental health issues including presence of depression, thought disorders, or behavioral or mood problems; * Personality including how a person copes with challenging situations; * Vision and speech; * Activities of daily living including toileting and bladder management and dental status; * Pain including pharmaceutical and non-pharmaceutical interventions; * Nutrition habits, fluid preferences, and weight; * List of treatments including type, frequency, and level of assistance needed; * Indicators of nursing needs including potential for delegated nursing tasks; * History of dehydration or unexplained weight loss or gain; * Recent losses; * Unsuccessful placements; and * Environmental factors that impact the residents behavior including, but not limited to noise, lighting, and room temperature. The need to ensure move-in evaluations addressed all required elements was reviewed with Staff 1 (Director of Assisted Living) and Staff 2 (VP of Health & Wellness) on 10/09/24 at 1:59 pm. They acknowledged the findings.

1. Resident 1’s service plan was updated on 10/21 to include the following required elements (where applicable): customary routines including sleeping, eating, and bathing; physical health status including list of current diagnosis; mental health issues including presence of depression, thought disorders, or behavioral or mood problems; personality including how a person copes with challenging situations; vision and speech; activities of daily living including toileting and bladder management and dental status; pain including pharmaceutical and non-pharmaceutical interventions; nutrition habits, fluid preferences, and weight; list of treatments including type, frequency, and level of assistance needed; indicators of nursing needs including potential for delegated nursing tasks; history of dehydration or unexplained weight loss or gain; recent losses; unsuccessful placements; and environmental factors that impact the resident’s behavior including, but not limited to noise, lighting, and room temperature. 2. The Community’s Initial Evaluation tool will be modified to ensure move-in evaluations address all of the required elements identified under OAR 411-054-0034(3)(c). Both the tool and any policies and procedures related to the Initial Evaluation and Service Plan will be updated to reflect these requirements. 3. All staff involved in the move-in evaluation process will be in-serviced on these requirements on or before 11/30. This includes but is not limited to the Administrator, Director of Nursing Services, Resident Care Coordinator, and admission nurses. 4. The Administrator and Director of Nursing Services will audit all move-in evaluations monthly for the next 90 days to ensure compliance with regulations. Findings will be reviewed at the Community’s quarterly Quality Assurance meeting and corrective action will be implemented as needed.

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 and provided clear direction regarding the delivery of services for 1 of 3 sampled residents (#1) whose service plans were reviewed. Findings include, but are not limited to: Resident 1 was admitted to the facility in 08/2024 with diagnoses including a suprapubic catheter and chronic pain. The residents current service plan, dated 09/04/24, and Member Interim Service Plans, dated 08/13/24 through 09/27/24 revealed the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas: ? * Use of assistive devices including a sit-to-stand with instruction to staff; * Transfer assistance needed, use of transfer pole when transferring in and out of bed, and instruction to staff; * Diagnosis of abdominal hernia and instruction to staff; * Catheter site to be changed, by who, and frequency; * Use of catheter with instruction for catheter bag changes in morning and evening; * Instruction to staff regarding placement of catheter bag in grey bin; * Frequency of meals, preferences, and where resident ate meals; * Use of power w/c including how to park when using bathroom; * Shower assistance needed and instruction to staff; * Outside providers involved in care; * Use of manual wheelchair for appointments; * Chronic pain in knees due to arthritis and staff non-pharmacological interventions; * Life enrichment including resident interests and assistance needed; * Weight record; * Preferred time to wake-up for morning routine; and * Preferred time to be assisted with evening routine and bedtime. On 10/07/24 at 12:03 pm, a transfer pole was observed, and Staff 5 (CG) confirmed the use of the transfer pole. The need to ensure resident service plans were reflective of current care needs and provided clear direction regarding the delivery of services was discussed with Staff 1 (Director of Assisted Living) and Staff 2 (VP of Health & Wellness) on 10/09/24 at 1:59 pm. They acknowledged the findings.

1. Resident 1’s service plan was updated on 10/21 to provide clear direction regarding the delivery of services related to: use of assistive devices including a sit-to-stand with instruction to staff; transfer assistance needed, use of transfer pole when transferring in and out of bed, and instruction to staff; diagnosis of abdominal hernia and instruction to staff; catheter site to be changed, by who, and frequency; use of catheter with instruction for catheter bag changes in morning and evening; instruction to staff regarding placement of catheter bag in grey bin; frequency of meals, preferences, and where resident ate meals; use of power wheelchair including how to park when using bathroom; shower assistance needed and instruction to staff; outside providers involved in care; use of manual wheelchair for appointments; chronic pain in knees due to arthritis and staff non-pharmacological interventions; life enrichment including resident interests and assistance needed; weight record; preferred time to wake-up for morning routine; and preferred time to be assisted with evening routine and bedtime. 2. The Community’s evaluation tools and any policies and procedures related to Service Plans will be updated no later than 11/30 with instructions on the provision of clear direction regarding a resident’s current care needs and the delivery of services to meet those needs, including written descriptions of who shall provide the services and what, when, how, and how often the services shall be provided. 3. All staff involved in the resident evaluation process and creation of service plans will be in-serviced on this requirement on or before 11/30. This includes but is not limited to the Administrator, Director of Nursing, Resident Care Coordinator, and admission nurses. 4. The Resident Care Coordinator will be responsible for ensuring service plans are updated after quarterly reviews and change of conditions in accordance with this rule. 5. The Administrator or designee will conduct Service Plan audits of 10% of the resident census monthly for the next 90 days to ensure compliance with regulations, then quarterly thereafter. Findings will be reviewed at the Community’s quarterly Quality Assurance meeting and corrective action will be implemented as needed.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused to consent to orders for 1 of 1 sampled resident’s (# 2) who had documented medication refusals. Findings include, but are not limited to: Resident 2's clinical records and MARs/TARs were reviewed during the survey and revealed the resident had multiple medication refusals on 10/01/24 and 10/06/24, including but not limited to: Polyethylene Glycol, routine daily (for constipation). There was no documented evidence the facility notified the physician when the resident refused consent to their orders. On 10/09/24 the failure to notify physicians of the documented medication and treatments refusals was reviewed with Staff 1 (Administrator), Staff 2 (VP of Health and Wellness), Staff 3 (Director of Health Services), and Staff 4 (RN). They acknowledged the findings. No further documentation was provided.

1. Resident 2’s physician was notified of resident 2’s refusal of a Polyethylene Glycol order on 10/8, 10/9, 10/10, 10/11, 10/12, 10/13, 10/14, and 10/15. Physician’s preference for further notification of medication refusals was also requested at this time. Resident's physician was called on 10/15/24 and confirmed receipt of faxes regarding the medication refusals. Resident's physician instructed nurse to continue scheduled medication and requested to be notified weekly of any refusals. Order added to the TAR instructing nurses to notify resident's physician of any medication refusals every week on Fridays. 2. The Community’s policy on Medication/Treatment Refusals will be reviewed and updated as needed by the Administrator no later than 11/30/24. 3. All staff (medication aides/techs, nurses) involved in the administration of medications or treatments will be in-serviced on or before 11/30/24 on the Community’s policy on Medication/Treatment Refusals and the requirement to notify the prescriber if a resident refuses consent to an order. 4. The Resident Care Coordinator will audit all resident records no later than 11/30 to ensure the Community has instructions from each resident’s prescriber regarding the frequency of notification when a resident refuses consent to an order. 5. The Director of Nursing Services or designee will conduct MAR/TAR audits of 10% of the resident census monthly for the next 90 days to ensure compliance with regulations, then quarterly thereafter. Findings will be reviewed at the Community’s quarterly Quality Assurance meeting and corrective action will be implemented as needed.

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 8, 10, and 11) were trained in the use of the abdominal thrust and First Aid within 30 days of hire. Findings include, but are not limited to: Training records were reviewed on 10/09/24 and identified the following: Staff 8 (CG), hired 08/05/24, Staff 10 (CG), hired 08/05/24, and Staff 11 (CG), hired 08/12/24, lacked documentation of demonstrated competency in First Aid/Abdominal Thrust. During an interview on 10/09/24, Staff 2 (VP of Health & Wellness) confirmed the lack of documented evidence the above sampled staff completed first aid and abdominal thrust training. The need to ensure staff demonstrated competency in the use of abdominal thrust and First Aid within 30 days of hire was discussed with Staff 1 (Director of Assisted Living) and Staff 2 on 10/09/24. They acknowledged the findings.

1. Staff 8 and 11 completed Frist Aid and abdominal thrust training on 10/28. Staff 10 will complete First Aid and abdominal thrust training on 11/11/24. 2. The Staffing Manager will audit all direct care new hire records for compliance regarding the completion of First Aid and abdominal thrust training within 30 days of hire. Staff missing the required training will complete the training on or before 11/30/24. 3. Policies and procedures related to direct care new hire training requirements will be review/updated as needed by the Administrator no later than 11/30/24. 4. Staff responsible for overseeing the onboarding of direct care new hires will be in-serviced on required trainings and the Community’s policies on or before 11/30/24 to ensure compliance with the rule going forward. 5. The Administrator or designee will audit training records for direct care new hires monthly for the next 90 days to ensure compliance with regulations, then quarterly thereafter. Findings will be reviewed at the Community’s quarterly Quality Assurance meeting and corrective action will be implemented as needed.

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 instruct residents within 24 hours of admission and re-instruct residents, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. Findings include, but are not limited to: On 10/07/24 the facility fire and life safety records were reviewed. The facility lacked documented evidence that residents were instructed within 24 hours of admission and re-instructed, at least annually, on general safety procedures, evacuation methods, and responsibilities. On 10/08/24 at 12:33 pm, Staff 1 (Director of Assisted Living) and Staff 2 (VP of Health & Wellness) confirmed the current system was not for the instruction of fire and life safety procedures. The need to ensure that residents received instruction in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area, within 24 hours of admission and re-instruct residents, at least annually, was reviewed with Staff 1 and Staff 2 on 10/09/24 at 1:59 pm. They acknowledged the findings.

1. Policies and procedures related to Fire and Life Safety training for residents will be review/updated by the Administrator to reflect requirements in association with this rule no later than 11/30/24. The policy will instruct designated staff to provide Fire and Life Safety training to residents within 24 hours of admission and re-instruction annually, and will include 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. Instructions will be provided to resident’s legal representative for those with limited cognitive capacity. 2. The Resident Care Coordinator or designee will be responsible for ensuring residents receive instruction on Fire and Life Safety procedures within 24 hours of admission. Training provided will be documented on the new admission checklist and in the resident’s electronic health record. 3. All residents will receive annual Fire and Life Safety training no later than 11/30/24. The Administrator will be responsible for ensuring all residents receive annual instruction going forward during the month of June each year. A written record of fire safety trainings, including content of the training sessions and the residents attending, will be retained by the Administrator. 4. The Administrator or designee will audit Fire and Life Safety training records for all new admissions monthly for the next 90 days to ensure compliance with regulations, then quarterly thereafter. Findings will be reviewed at the Community’s quarterly Quality Assurance meeting and corrective action will be implemented as needed.

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 were maintained in good repair. Findings include, but are not limited to:? The exterior of the facility was toured on 10/07/24 at 9:20 am, and the following was identified: A stair pathway located on a steep hillside that was not maintained in good repair. This created a potential hazard for residents. The exterior courtyard was toured with Staff 1 (Director of Assisted Living) on 10/09/24 at 10:45 am. She acknowledged the findings.

1. It is the Community’s practice to ensure exterior pathways and accesses to common-use areas, entrances, and exits are well-maintained and in good repair. Access to the exterior stair pathway located on the hillside will be restricted by a gate or chain to eliminate any potential hazards for residents. 2. Access will remain restricted by agate or chain. Residents requesting access to the stairway will be assessed for safety before access is granted. 3. The Administrator will conduct environmental audits of all resident exterior common-use spaces, entrances and exits with the Director of Facilities monthly to ensure the extierioe of the building and grounds maintained and in good repair. 4. Requests for repairs will be submitted as needed. Identified issues will be monitored through the Community’s quarterly Quality Assurance meeting, including actions taken to address the issue.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (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 the 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. A RCF 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 will 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 all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: The interior of the facility was toured on 10/07/24 at 9:20 am and the following was identified: * The primary laundry room floor had multiple large pieces missing and/or was cracked or chipped around the perimeter of the room, under and behind the washing machines, and around floor drains; * The second laundry room had flooring that was worn down and/or missing throughout; * The dining room had two cabinet sets that had heavily worn surfaces and were not smooth to touch; * The common area restrooms had cabinets that had heavily worn surfaces and were not smooth to touch; and * The common area restroom located near the dining room, had pooled water under it throughout survey and was observed to spray water when flushed. The interior of the facility was toured with Staff 1 (Director of Assisted Living) on 10/09/24 at 10:45 am. She acknowledged the findings.

1. It is the Community’s practice to ensure interior materials and surfaces are kept clean and in good repair for the health, safety and comfort of our residents. In response to the findings identified during the survey period, the community will initiate repairs to the following: a. The primary laundry room not found to be in good repair evidenced by missing and/or cracked/chipped floor pieces around the perimeter of the room, under and behind washing machines, and around floor drains will be resurfaced with an epoxy material to ensure a smooth, consistent and cleanable surface. b. The hallway laundry room floor will be resurfaced with an epoxy material to ensure a smooth, consistent and cleanable surface. c. The dining room cabinets will be resurfaced to ensure surfaces are smooth to touch and in good repair. d. The common area restroom cabinets will be resurfaced to ensure surfaces are smooth to touch and in good repair. e. The water flow of the toilet in the common area restroom will be adjusted to prevent it from spraying water onto the floor when flushed. 2. The Administrator will conduct environmental audits of all resident common spaces with the Director of Facilities monthly to ensure the interior of the building is clean and in good repair. 3. Requests for repairs will be submitted as needed. 4. Identified issues will be monitored through the Community’s quarterly Quality Assurance meeting, including actions taken to address the issue.

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all exit door alarms alerted staff when residents exited the facility. Findings include but are not limited to: The interior of the facility was toured on 10/07/24 at 9:20 am, and two exit doors to the courtyard were identified. One exit had a sign that read “Alarm will sound when door opened” and when opened an audible alarm did not sound. On 10/07/24 at 11:10 am, Staff 5 (CG) stated when the exit door opened, an alert would appear on her hand-held device and showed this surveyor the notification. At 11:11 am, Staff 5 opened the exit doors located in the dining room and her hand-held device did not receive a notification. On 10/07/24 at 11:25 am, Staff 2 (VP of Health & Wellness) was notified the exit doors in the dining room did not alert staff when opened. Staff 2 tested the alarm system and immediately submitted a work order to have the exit door alarm fixed. The need to ensure all exit door alarms alerted staff when residents exited the facility was reviewed with Staff 1 (Director of Assisted Living) and Staff 2 on 10/09/24 at 1:59 pm. They acknowledged the findings.

1. On 10/7, a work order was submitted regarding a notification not being sent to the caregiver’s hand-held device when the exit door from the dining room to the exterior patio was opened. The issue was corrected that same day. Both the Administrator and Surveyor tested the door to make sure it was sending appropriate notifications. 2. The Administrator or designee will inspect all exterior exit doors monthly to ensure door alarms are functioning properly. 3. Any concerns identified will be addressed immediately and an alternative plan for safety will be implemented, as needed. 4.Identified issues will be monitored through the Community’s quarterly Quality Assurance meeting, including actions taken to address the issue.