OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: ?Based on interview and record review, it was determined the facility failed to report incidents of abuse or suspected abuse to the local Seniors and People with Disabilities (SPD) office, ensure injuries of unknown cause were reported to the local SPD office unless an immediate facility investigation reasonably concluded the injury was not the result of abuse, and/or to ensure documentation of Administrator review on facility investigations of abuse or suspected abuse for 4 of 4 residents (#s 2, 3, 5, and 7) who had incidents that were reviewed. Findings include, but are not limited to: 1. Resident 7 moved into the facility in 11/2022 with diagnoses including type 2 diabetes and hypertension. The resident’s 12/08/24 to 01/21/25 progress notes, temporary service plans, and current service plan were reviewed. Interviews with staff and the resident were conducted. During an interview at 1:25 pm on 01/21/25, Resident 7 stated his/her social security card had been stolen on an unknown date, and s/he had recently had $20,000.00 stolen from his/her bank account on or around 12/30/24. The above incidents constituted possible financial abuse/neglect which required immediate reporting to the local SPD office. During an interview at 11:42 am on 01/22/25, Staff 1 (ED) stated the incidents had not been reported. Survey requested the incidents be reported to the local SPD, and confirmation was received at 8:00 am on 01/23/25. The need to ensure incidents of abuse were immediately reported to the local SPD office was discussed with Staff 1 on 01/24/25. She acknowledged the findings. 2. Resident 2 moved into the facility in 04/2023 with diagnoses including Parkinson’s disease and a history of falls. The resident’s 10/22/24 to 01/21/25 progress notes, temporary service plans, incident reports, and investigations were reviewed. The following was identified: The resident experienced an unwitnessed injury fall on 11/03/24 and an unwitnessed noninjury fall on 12/11/24. The facility investigations lacked documentation of the following: * Administrator review. During an interview at 11:42 am on 01/22/25, Staff 1 (ED) confirmed there had not been a system in place for Administrator review of investigations. The need to ensure facility investigations of abuse or suspected abuse included documentation of Administrator review was discussed with Staff 1 on 01/24/25. She acknowledged the findings. ?3. Resident 3 was admitted to the facility in 09/2022 with diagnoses including Alzheimer’s disease and anxiety disorder. The resident's 12/31/24 service plan, any available incident reports and/or investigations, progress notes and short-term observations (STOs) dated 10/21/24 to 01/21/25 were reviewed, and interviews with staff were conducted. The following was identified: a. On 12/17/24, progress notes and home health notes described a wound to the resident’s right elbow: * Progress note – “New orders or changes to treatment plan: Wound care to R elbow”; and * Home health note – “Dressing to R elbow not assessed as [resident] not engaging with care.” There was no documentation of how the resident sustained the elbow wound. There was no documented evidence that an immediate investigation occurred and ruled that the wound was not the result of abuse or neglect or that the injury of unknown cause was reported to the local (SPD) office. At the request of survey, the injury of unknown cause was reported to the local SPD office on 01/24/25 at 4:11 pm. b. The resident experienced unwitnessed noninjury falls on 11/13/24, 12/24/24, 12/31/24 and 01/18/25. The facility investigations lacked documentation of the following: * Administrator review. The need to ensure injuries of unknown cause were reported to the local SPD office unless an immediate investigation ruled out abuse, and investigations included all required components, was reviewed on 01/24/25 at 10:30 am with Staff 1 (ED), Staff 3 (Resident Services Director) and Staff 4 (LPN). They acknowledged the findings. 4. Resident 5 moved into the facility in 05/2023 with diagnoses including generalized anxiety disorder and mild cognitive impairment. The resident's record, including progress notes, temporary service plans, incident reports, and investigations were reviewed. The following was identified: On 12/25/24, Resident 5 reported bruises on his/her legs to staff and claimed they were caused by his/her spouse. This represented an incident of abuse or suspected abuse which required immediate reporting to the local SPD office. There was documented evidence the facility reported the incident to the local SPD office on 12/31/24, six days after the incident occurred. During an interview on 01/24/25 at 9:45 am, Staff 1 (ED) acknowledged the incident had not been reported to the local SPD office immediately. The need to immediately report incidents of abuse or suspected abuse to the local SPD office was discussed with Staff 1 on 01/24/25. The findings were acknowledged.

1. For resident 7, a self-report was submitted to SPD on 1/22/25 for claims of losing her social security card and money missing from her bank account. ED and WD completed and documented the investigation, including interventions as identified, for suspected theft. For Resident 3, a self-report was submitted to SPD on 1/24/25 for the wound of unknown origin. ED and WD completed and documented the investigation for the root cause of the wound. Resident #3’s service plan was updated to reflect the wound and interventions as identified in the investigation. For Residents #2 and #3, the ED reviewed and documented review of all investigations. 2. Timely documentation for all incidents requiring root cause analysis and abuse/neglect investigation. Incident investigation and documentation will occur timely. All suspected abuse and neglect, or abuse/neglect that cannot be ruled out, will be reported to SPD per reporting requirements. All-staff in-service conducted by 3/25/25 to review Oregon Abuse and Neglect Reporting guidelines, community process for investigating suspected abuse/neglect, timely reporting to SPD, and chain of command for the process. 3. Timely for incidents; before filing documentation 4. Executive Director, Wellness Director, Associate Wellness Director

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure injuries of unknown cause were reported to the local Seniors and People with Disabilities (SPD) office unless an immediate investigation reasonably concluded and documented physical injuries were not the result of abuse, and failed to ensure incident investigations were completed promptly and included all required elements for 1 of 1 sampled resident with incidents of abuse or suspected abuse (#8). This is a repeat citation. Findings include, but are not limited to: 1. Resident 8 was admitted to the facility in 09/2024 with diagnoses including dementia and Type 2 diabetes. The resident's 03/25/25 through 05/07/25 progress notes, temporary service plans, skin and wound evaluations, Incident/Accident Reports and Post Incident Worksheets were reviewed, and interviews with staff were conducted. The following was identified: a. On 04/08/25, the resident was identified to have a new skin tear on his/her elbow, and the incident report stated, “resident does not know how [s/he] got it.” The facility did not complete an immediate investigation which reasonably concluded and documented that the physical injury was not the result of abuse, and did not immediately report the injury to the local SPD office. The incident was investigated on 04/10/25. b. The facility failed to promptly investigate, and document all required components of an investigation, for the following incidents: *On 04/21/25 the resident experienced an unwitnessed fall with injury. Documentation stated the resident was “found on the floor in front of [his/her] toilet leaning against it. Blood and urine on the floor. [S/he] also had BM on [the resident] [his/her] rug and [his/her] toilet. [The resident] had skin tears on [his/her] left arm, ear and an abrasion on [his/her] left shoulder. [The resident’s] left eye was severely red, swollen and [s/he] stated [s/he] could not see out of it.” The investigation did not include all required components, including follow up action and Administrator's review. *On 04/23/25, the resident experienced an unwitnessed fall with re-injury to previous skin tears. The investigation did not include all required components, including the response of staff at the time of the incident. The need to ensure all injuries of unknown cause were immediately reported to the local SPD unless an immediate investigation reasonably concluded that the injury was not the result of abuse, and investigations occurred promptly and documented all required components was reviewed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (Resident Services Director) and Staff 22 (LPN/Wellness Director) on 05/09/25 at 1:10 pm. They acknowledged the findings.

1. For resident 8, regarding the skin tear on his elbow from 4/8/25, a thorough investigation was conducted and concluded. Following the investigation, because abuse and neglect could not be ruled out, the injury was reported on 5/22/25, to the local SPD office. For resident 8, regarding the unwitnessed fall from 4/21/25, a thorough investigation was conducted and concluded. Follow up action was determined and the Administrator reviewed and signed the documentation following investigation completion. For resident 8, regarding the unwitnessed fall with re-injury on 4/23/25, a thorough investigation was conducted and concluded. The investigation and documentation includes all of the required components, including response of staff at the time of the incident. 2. The system will be corrected through thorough investigations, including all required components for all incidents requiring root cause analysis. Unless immediate investigation can reasonably conclude that the an injury was not the result of abuse or neglect, it will be immediately reported to local SPD. Investigations occur timely and include all required components. The licensed nurses and administrator will take courses addressing fall Investigation and Root Cause Analysis. All staff will complete Elder Abuse Prevention, Investigation and Reporting training through Oregon Care Partners by 5pm on June 19th, 2025. 3. Weekly. 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 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure actions/interventions were determined, documented, and communicated to staff on each shift with monitoring and weekly progress noted to resolution for 4 of 6 sampled residents (#s 3, 4, 5, and 6) who had short-term changes of condition. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 09/2022 with diagnoses including Alzheimer’s disease and anxiety disorder. The resident's 12/31/24 service plan, progress notes, and temporary service plans dated 10/21/24 to 01/21/25 were reviewed, and interviews with staff were conducted. The following short-term changes of condition, documented in the progress notes, lacked actions or interventions, determined, documented, communicated to staff on all shifts and/or were not monitored at least weekly to resolution: *12/13/24 – Change in level of assistance needed following hip fracture; *12/13/24 – Right hip post-operative incision; *12/17/24 – Right elbow wound; *12/24/24 – Unwitnessed fall; *12/31/24 – Unwitnessed fall; *01/07/25 – Change in level of assistance required with transfers; and *01/08/25 – Vomiting. The need to ensure short-term changes of condition had actions or interventions determined, documented, and communicated to staff on all shifts, and were monitored at least weekly to resolution was reviewed on 01/24/25 at 10:30 am with Staff 1 (ED), Staff 3 (Resident Services Director) and Staff 4 (LPN). They acknowledged the findings, and no additional information was provided. 2. Resident 6 was admitted to the facility in 12/2021 with diagnoses including type 2 diabetes and chronic pain. The resident's 12/06/24 service plan and progress notes and temporary service plans dated 10/21/24 to 01/21/25 were reviewed, and interviews with staff were conducted. The following short-term change of condition, documented in the progress notes, lacked actions or interventions communicated to staff on all shifts and/or was not monitored at least weekly to resolution: *11/23/24 – Right hand swelling. The need to ensure all changes of condition had actions or interventions determined, documented, and communicated to staff on all shifts, and were monitored at least weekly to resolution was reviewed on 01/24/25 at 10:30 am with Staff 1 (ED), Staff 3 (Resident Services Director) and Staff 4 (LPN). They acknowledged the findings, and no additional information was provided. ?3. Resident 4 moved into the facility in 09/2018 with diagnoses including hemiplegia and hemiparesis of right dominant side. The resident's 10/21/24 to 01/21/25 progress notes and temporary service plans were reviewed, and interviews with staff were conducted. The following was identified: There was no documented evidence the facility identified actions/interventions, communicated them to staff on each shift, and/or monitored with weekly progress noted to resolution the following short-term changes of condition: * 11/11/24 – Changed antibiotic; and * 11/16/24 – Increased confusion. The need to ensure actions/interventions were determined, documented, and communicated to staff on each shift and weekly progress was noted to resolution for short-term changes of condition was discussed with Staff 5 (LPN) on 01/23/25 and Staff 1 (ED) on 01/24/25. The findings were acknowledged, and no additional information was provided. 4. Resident 5 moved into the facility in 05/2023 with diagnoses including peripheral vascular disease, generalized anxiety disorder, and mild cognitive impairment. The resident's 10/21/24 to 01/21/25 progress notes and temporary service plans were reviewed, and interviews with staff were conducted. The following was identified: a. There was no documented evidence the facility identified actions/interventions, communicated them to staff on each shift, and/or monitored with weekly progress noted to resolution for the following short-term changes of condition: * 12/31/24 – Resident exhibited behaviors; and * 01/13/25 – Resident exhibited behaviors. b. There was no documented evidence the facility communicated actions/interventions to staff on each shift, and/or monitored with weekly progress noted to resolution for the following short-term change of condition: * 01/12/25 – New bruising to legs. The need to ensure actions/interventions were determined, documented, and communicated to staff on each shift and weekly progress was noted to resolution for short-term changes of condition was discussed with Staff 5 (LPN) on 01/23/25 and Staff 1 (ED) on 01/24/25. The findings were acknowledged, and no additional information was provided.

1) Resident #3 was assessed for a history of right hip fracture and incision, right elbow wound, unwitnessed falls, assistance required with transfers, and history of vomiting. Nursing documented assessment, root cause analysis, and interventions as identified to address changes in condition. Nursing updated the service plan to reflect Resident #3’s current needs and effective/non-effective interventions as identified for falls and wound. Resident #6 was assessed for right-hand swelling. The nurse documented assessment and interventions as identified. The service plan was updated. Resident #4 was assessed for antibiotic use and confusion and the service plan was updated to reflect current conditions. Resident #5 was assessed for behaviors exhibited per chart and leg bruising. The service plan was updated to reflect current conditions. Any identified unresolved short-term changes will be placed on monitoring and monitored at least weekly until resolution. 2) Review of Temporary Service Plans (TSPs), electronic healthcare record, 24/72 hour report, and clinical alert log for changes in condition. At minimum weekly review and documentation of all changes in condition until resolution. TSP and the clinical alert log will be updated based on the evaluation of the resident condition and interventions. 3) Frequently and timely 4) Wellness Director, Associate Wellness Director, Resident Services Director

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had a significant change of condition were evaluated, referred to the RN for assessment and the service plan was updated as needed and/or failed to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff on all shifts, and document weekly progress until the condition resolved for 4 of 4 sampled residents (#s 8, 9, 10 and 11) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to: 1. Resident 8 was admitted to the facility in 09/2024 with diagnoses including dementia and Type 2 diabetes. The resident's current service plan, dated 04/18/25, and 03/18/25 through 05/07/25 progress notes, skin and wound evaluations, and temporary service plans were reviewed, interviews with staff were conducted, and observations of the resident were completed. The following was identified: The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and/or monitoring at least weekly through resolution: *03/18/25 – Right medial ankle wound; *03/24/25 – Left ankle abrasion; *04/03/25 – Fall with injury; *04/17/25 – New medication; *04/21/25 – Unwitnessed fall with injury; and *04/21/25 – Injuries to left shoulder and left ear. The need to ensure the facility determined and documented what action or interventions were needed for short-term changes of condition, communicated the interventions to staff on all shifts and monitored the short-term changes of condition at least weekly through resolution was reviewed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (Resident Services Director) and Staff 22 (LPN/Wellness Director) on 05/09/25 at 1:10 pm. They acknowledged the findings. 2. Resident 11 was admitted to the facility in 05/2023 with diagnoses including major depressive disorder and hypertension. The resident's most recent service plan, dated 02/04/25, and 03/25/25 through 05/07/25 progress notes, temporary service plans, skin and wound evaluations and home health wound care notes were reviewed, interviews with staff were conducted, and observations of the resident were completed. The following was identified: a. The resident returned to the facility on 03/07/25, per progress note dated 3/27/25, after a hospital stay with diagnoses including pneumonia and cellulitis. Prior to the resident’s hospital stay, on 02/28/25, the resident weighed 175 pounds. On 03/28/25, the resident’s weight was documented as 161 pounds. This constituted a severe weight loss of 14 pounds, or 8%, in one month. There was no documented evidence the weight loss was evaluated and referred to the RN. On 04/09/25 the resident’s weight was 169.6, and on 05/08/25 the resident’s weight was 169.2. Staff 2 (RN) completed a significant change of condition assessment on 04/10/25. In an interview on 05/09/25 at 11:30 am, Staff 2 stated she completes weight monitoring once per month, unless the electronic charting system alerts her that a change has occurred. She stated she was not immediately alerted of the resident’s weight loss and did not complete an assessment until 04/10/25. b. The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and/or monitoring at least weekly through resolution: *03/27/25 – Right shin wound; *03/28/25 – New medication; *04/17/25 – Symptoms of wound infection; *04/24/25 – Wound dressed improperly resulting in skin injury; *Approximately 05/06/25 – Left knee wound identified by home health. The need to ensure the facility evaluated residents who experienced significant changes of condition, referred the resident to the facility nurse, documented the change and updated the service plan as needed; and determined and documented what action or interventions were needed for short-term changes of condition, communicated the interventions to staff on all shifts and monitored the short-term changes of condition at least weekly through resolution was reviewed with Staff 1 (Executive Director), Staff 2, Staff 3 (Resident Services Director) and Staff 22 (LPN/Wellness Director) on 05/09/25 at 1:10 pm. They acknowledged the findings. 3. Resident 9 was admitted to the facility in 03/2025 with diagnoses including polyneuropathy and a history of repeated falls. The resident’s 03/25/25 through 05/07/25 progress notes, temporary service plans (TSPs), Incident/Accident Reports, investigations, and the current service plan were reviewed. The resident and staff were interviewed. Resident 9 experienced eight falls between 04/01/25 and 05/03/25: * 04/01/25 – unwitnessed, with no visible injury. The 05/07/25 investigation indicated previous fall interventions were effective and determined additional interventions, including routine checks, reminders to ask for assistance, help with ensuring walkways are safe. There was no documented evidence these interventions were communicated to staff. * 04/07/25 – unwitnessed, with no visible injury. The 05/07/25 investigation noted some previous interventions were ineffective because “[s/he] likes [his/her] independence” and “does not always allow staff assist” with ADLs. Interventions included “temporary” increased safety checks and reminders to call staff for assistance with getting undressed. There was no documented evidence these interventions were communicated to staff. * 04/21/25 – unwitnessed, with no visible injury. The resident stated they slipped because there was water on the bathroom floor. The 04/22/25 investigation indicated previous fall interventions were effective. The intervention was for staff to ensure water was wiped up off the floor after showers to prevent slips and falls. There was a corresponding TSP dated 04/22/25 for that intervention. Additional documentation attached to the investigation indicated staff should do “routine safety checks at mealtimes and at HS [bedtime] to ensure in safe position while in room.” There was no documented evidence the safety checks intervention was communicated to staff. * 04/27/25 – unwitnessed. The resident reported s/he fell in the bathroom, hitting her head. An 04/29/25 investigation identifies previous interventions which were ineffective, including using his/her walker in their apartment and calling staff for assistance. A TSP dated 04/29/25 instructed staff to ensure the resident’s walker was placed in front of his/her recliner to prompt the resident to use it in his/her apartment. * 04/28/25 – unwitnessed, with no visible injury. The resident reported to staff his/her feet got caught in the blankets on the bed and s/he fell out of bed onto the floor. The 04/29/25 investigation noted the previous intervention of the resident using his/her walker while in his/her apartment was ineffective. A TSP dated 04/29/25 instructed staff to ensure blankets were up on the bed off the floor and end of blankets were tucked into the end of bed when doing safety checks on the overnight shift. * 05/01/25 – The resident fell and hit his/her head when out of the facility with his/her family, who took him/her to the ER. * 05/02/25 – unwitnessed, with no visible injury. Resident 9 stated s/he tripped on the carpet while walking to his/her recliner after using the bathroom. The 05/06/25 investigation noted some previous interventions were ineffective and documented new interventions as hourly checks and “PCP apt [sic] scheduled 5/7/25.” The TSP for the 05/01/25 fall included hourly checks. * 05/03/25 – unwitnessed, with no visible injury. The resident told staff s/he slid out of bed but had no pain and had not hit his/her head. The 05/06/25 investigation documented previous interventions were ineffective and noted the same interventions as were documented for the 05/02/25 fall. There was no documented evidence the facility consistently evaluated previous interventions for effectiveness, determined and implemented new interventions, or communicated new interventions to staff. The need to consistently determine and document interventions, monitor interventions for effectiveness, and document progress at least weekly through resolution was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (Residential Services Director), and Staff 22 (LPN / Wellness Director) on 05/09/25 at 12:40 pm. 4. Resident 10 was admitted to the facility in 04/2024 with diagnoses including Parkinson’s disease. The resident’s current service plan and 03/25/25 through 05/07/25 progress notes, Incident/Accident Reports, investigations, and temporary service plans were reviewed, and staff were interviewed. Resident 10 experienced nine falls between 03/26/25 and 05/04/25: * 03/26/25 – unwitnessed fall, with no visible injury. The resident stated s/he “missed a step.” The 03/28/25 investigation noted, “[The resident] likes [his/her] independence [sic] is resistive to accepting help.” Staff 2 (RN) documented the resident was “agreeable” to letting staff know when s/he was tired so they could provide standby assistance for safety. There was a corresponding TSP dated 03/28/25. * 04/01/25 – unwitnessed, with no visible injury. Resident 10 reported to staff s/he lost his/her balance while walking in her apartment and “went to sit on waste basket next to chair to wait for staff, but it gave out which was how [the resident] was on floor.” Staff noted the resident’s walker was in front of him/her. The 04/07/25 investigation noted previous interventions were ineffective because “[Resident] likes independence [sic] will not let staff assist” with ADLs. The new intervention was to remind the resident not to sit on the garbage can when waiting for staff. There was no documented evidence the new intervention was communicated to staff. * 04/04/25 – unwitnessed, with no visible injury. The resident reported s/he was trying to sit on his/her chair and completely missed it and fell on the floor. The 04/07/25 investigation noted current interventions were effective and added an intervention to offer standby assistance for transfers. Staff 2 (RN) documented the resident was “resistive and wishes to remain independent.” There was no documented evidence the new intervention was communicated to staff. * 04/19/25 – unwitnessed, with no visible injury. Resident 10 told staff s/he was “reaching back” into his/her closet and fell down. The 04/22/25 investigation indicated previous interventions were effective, and that “PT, frequent checks, neurology, med adjustments” continued. There was no documented evidence new interventions were determined or communicated to staff. * 04/21/25 – unwitnessed, with no visible injury. The resident reported to staff s/he lost his/her balance while turning. The 04/22/25 investigation noted previous interventions were ineffective and that the resident “has parkinsons [sic] likes independence, will not ask for help.” A new intervention was documented on a TSP dated 04/23/25, instructing staff to set out the resident’s clothes for the next day when s/he went to bed. * 04/24/25 – unwitnessed, with no visible injury. Resident 10 indicated to staff s/he had lost his/her balance while getting ready and hit his/her left arm. The 04/25/25 investigation noted previous interventions were not effective and documented the intervention from the 04/21/25 fall, that staff should lay out the resident’s clothes at night for the next day. There was no documented evidence new interventions were determined and communicated to staff. * 04/25/25 – unwitnessed, with no visible injury. The resident “was trying to sit on [his/her] chair, backing up to it and [his/her] foot got caught on the carpet, and had a fall on to [his/her] back.” The 04/29/25 investigation noted previous interventions were ineffective because the resident “refuses to accept help from staff despite encouragement to do so.” Staff 2 (RN) documented the resident “agreed to utilize her other walker while in apartment to see if this will reduce her falls.” In addition, garbage bins next to the recliner were moved back to prevent the resident “from having to back into recliner but rather try to sit from the side.” There was no documented evidence this information was communicated to staff. * 04/26/25 – unwitnessed, with no visible injury. The resident stated s/he “was getting a drink out of [his/her] fridge when [s/he] lost [his/her] balance and fell backwards onto [his/her] bottom.” The 04/29/25 investigation noted previous interventions were ineffective because the resident “refuses to ask staff for help despite reminders/encouragement.” A new intervention for the resident to use his/her “other walker while in apartment to see” if it would reduce falls was determined. Additional documentation attached to the investigation indicated the resident had a “self-locking walker,” in addition to the one s/he regularly used. There was no documented evidence the new intervention was communicated to staff. * 05/04/25 – unwitnessed, with a “small cut on [his/her] hand.” The Incident/Accident Report also indicated the resident had an “abrasion” on his/her right hand. The resident reported to staff that his/her “walker got away from [him/her] and [s/he] ended up on the floor.” The 05/07/25 investigation indicates prior interventions were not effective, that the resident was a “high fall risk,” liked to be independent, and would not ask staff for assistance. A new intervention was documented to increase safety checks and ask Staff 8 (Planter Operations Director) to “fix mechanism on door to apartment for greater lag time,” as it “may encourage [the resident] to utilize [his/her] locking walker.” There was no documented evidence staff were instructed to increase safety checks. There was no documented evidence the facility consistently evaluated determined and implemented new interventions or communicated new interventions to staff. The need to consistently determine and document interventions, monitor interventions for effectiveness, and document progress at least weekly through resolution was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (Residential Services Director), and Staff 22 (LPN / Wellness Director) on 05/09/25 at 12:40 pm.

1. For resident 8, the short term change of conditons identified between the dates 3/18/25 and 4/21/24, will be assessed and facility determined and documented what actions/interventions were needed, communication of the determined action and/or interventions will be communicated with staff via TSPs. All unresolved change of condtions will be monitored at least weekly through resolution. Active change of conditions will be monitored at least weekly through resolution. For resident 11, the short term change of conditions identified between the dates 3/27/25 and 5/6/25, will be asssessed for resident specific actions/interventions, communication of determined actions/interventions will be communicated with staff via TSPs. Active change of conditions will be monitored at least weekly through resolution. RN will be notified of identified significant change of conditions per regulation guidelines. For resident 9, falls between 4/1/25 and 5/3/25, facility will review all current documention for interventions and will evaluate effectiveness of previous and current interventions. Service plan will be updated to include history of intervention development, effective interventions, and new interventions. Effectivness of interventions will be monitored at least weekly through resolution. For resident 10, falls between 3/26/25 and 5/4/25, facility will review all current documention for interventions and will evaluate effectiveness of previous and current interventions. Service plan will be updated to include history of intervention development, effective interventions, and new interventions. Effectiveness of interventions will be monitored at least weekly through resolution. 2. TSP will be updated with successful/nonsuccessful interventions identified during investigation of incidents. From this date forward interventions will be monitored at least weekly through resolution to identify effectiveness. Service plan will be updated to include history of intervention development, effective interventions, and new interventions. Licensed Nurses and Administrator will take the following training through Nurselearn: Significant Change of Condition and Monitoring Series (1) Identifying, Assessing, and Monitoring Short Term and Signifcant Changes of Condition. Non-nurse manager will complete the short term changes of condition course via Relias. 3. Weekly, for courses by 6/23/25 4. WD, AWD, RN, RSD

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 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 2 of 2 sampled residents (#s 4 and 5) who had documented medication and/or treatment refusals. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 09/2018 with diagnoses including hemiplegia and hemiparesis of right dominant side. The resident's 01/01/25 through 01/21/25 MAR, physician orders, and progress notes dated 10/21/24 through 01/21/25 were reviewed. The following was revealed: Resident 4 had a physician’s order indicating to notify the prescriber of missed medications or medication refusals if the refusals occurred two days in a row. The resident refused to consent to orders for two days in a row for the following medication: * Refresh Classic Eye drops on 01/03/25 and 01/04/25, 01/10/25 and 01/11/25, 01/17/25 and 01/18/25, and 01/20/25 and 01/21/25. There was no documented evidence the facility notified the practitioner when Resident 4 refused to consent to orders for two consecutive days. During an interview on 01/23/25 at 12:38 pm, Staff 5 (LPN) confirmed the lack of prescriber notification. The need to ensure the facility notified the physician or other practitioner if the resident refused consent to an order was discussed with Staff 1 (ED) on 01/24/25. The findings were acknowledged. 2. Resident 5 moved into the facility in 05/2023 with diagnoses including anxiety disorder, mild cognitive impairment, and colostomy placement. The resident's 01/01/25 through 01/21/25 MAR, physician orders, and progress notes dated 10/21/24 through 01/21/25 were reviewed. Multiple medication and treatment refusals to consent to an order were revealed as follows: * 01/07/25 – 12 medication refusals and three treatment refusals; * 01/13/25 – 13 medication refusals; * 01/14/25 – 12 medication refusals and two treatment refusals; * 01/15/25 – 13 medication refusals; * 01/16/25 – Seven medication refusals; * 01/20/25 – One medication refusal and one treatment refusal; and * 01/21/25 – Two medication refusals and two treatment refusals. During an interview at 10:40 am on 01/23/25, Staff 5 (LPN) stated the practitioner would either receive a phone call or a fax, which would be documented in the progress notes if a resident refused to consent to a medication or treatment order. He confirmed there was no documented evidence regarding Resident 5's medication and treatment refusals. The need to ensure the facility notified the physician or other practitioner if the resident refused consent to an order was discussed with Staff 1 (ED) on 01/24/25. The findings were acknowledged.

1) For Resident 4, the physician was notified that the resident declined her eye drops for two days in a row. For Resident 5, her physician was notified of all refused medications as identified during the survey. 2) Inservice with all med staff and wellness management took place to review OAR requirements for notifying practitioners of refused medications. Electronic MAR will be reviewed for missed medications needing practitioner notification. 3) Routinely and timely; Monthly 4) Wellness Director, Associate Wellness Director, Resident Services Director

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 or other practitioner when a resident refused consent to an order for 1 of 1 sampled resident (#9) who refused orders. This is a repeat citation. Findings include, but are not limited to: Resident 9 was admitted to the facility in 03/2025 with diagnoses including polyneuropathy and a history of repeated falls. The resident’s 04/01/25 through 05/07/25 MARs and physician orders were reviewed. The following was identified: *Resident 9 refused nine different medications a total of 150 times between 04/01/25 and 04/30/25; and *The resident refused three different medications a total of 21 times between 05/01/25 and 05/07/25. There was no documented evidence the facility consistently notified the resident’s physician of his/her refusals. The need to notify the physician or other practitioner when the resident refused consent to an order was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (Resident Services Director), and Staff 22 (LPN / Wellness Director) on 05/09/25 at 12:40 pm. They acknowledged the findings.

1. For resident 9, the physician was notified of every refusal indentified between 4/1/25 and 5/7/25. 2. On 5/28/25, training was conducted with Medication associates regarding regulation for notifying prescribing provider of all medication refusals unless otherwise ordered. Audits are conducted to ensure communication with prescribing provider takes place. 3. Weekly. 4. WD, AWD, RSD.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by:

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept and PRN medications had resident-specific parameters and instructions for 4 of 6 sampled residents (#s 2, 3, 4, and 5) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 09/2022 with diagnoses including Alzheimer’s disease and anxiety disorder. Review of the resident's 01/01/25 to 01/21/25 MARs and physician orders revealed the following: a. The resident had an order for three lidocaine 4.88% patches to be applied once per day. The patches were documented as administered: * 01/04/25 through 01/09/25; * 01/11/25 through 01/12/25; * 01/15/25 through 01/17/24; and * 01/19/25. The patches were documented on the MAR as removed daily on 01/01/25 through 01/20/25. During an interview at 12:45 pm on 01/21/25, Staff 9 (MT) confirmed that the facility did not have the lidocaine patches to administer or remove from the resident during the above-documented dates. b. The resident had two PRN medications for pain. The MAR parameters stated, “when the resident experiences pain: administer PRN acetaminophen, if PRN acetaminophen is not effective after 1 hour administer tramadol.” On five dates, tramadol was administered without first administering acetaminophen. The need to ensure the MAR was accurate was reviewed on 01/24/25 at 10:30 am with Staff 1 (ED), Staff 3 (Resident Services Director) and Staff 4 (LPN). They acknowledged the findings, and no additional information was provided. ?2. Resident 4 was admitted into the facility in 09/2018 with diagnoses including hemiplegia and hemiparesis of right dominant side. The resident’s 01/01/25 to 01/21/25 MAR and physician orders were reviewed, and the following was identified: The resident had the following orders for PRN medications for constipation: * Fiber-lax capsule; and * Milk of magnesia. The MAR lacked instructions to unlicensed staff for which PRN medication to administer first. During an interview at 10:24 am on 01/23/25, Staff 5 (LPN) confirmed there were no parameters for the PRN bowel medications. The need to ensure resident-specific parameters and instructions for PRN medications was discussed with Staff 1 (ED) on 01/24/25. She acknowledged the findings. 3. Resident 5 moved into the facility in 05/2023 with diagnoses including anxiety disorder, mild cognitive impairment, and colostomy placement. The resident’s 01/01/25 to 01/21/25 MAR and physician orders were reviewed, and the following was identified: a. The resident had the following orders for PRN medications for constipation: * Fleet glycerin suppository; * Enema; and * Milk of magnesia. The MAR lacked instructions to unlicensed staff for which PRN medication to administer first. b. The resident had the following orders for PRN medications for pain: * Acetaminophen and * Tramadol. The MAR lacked instructions to unlicensed staff for which PRN medication to administer first. During an interview at 10:50 am on 01/23/25, Staff 5 (LPN) confirmed there were no parameters for the PRN bowel and pain medications. The need to ensure resident-specific parameters and instructions for PRN medications was discussed with Staff 1 (ED) on 01/24/25. She acknowledged the findings. 4. Resident 2 moved into the facility in 04/2023 with diagnoses including Parkinson’s disease. The resident’s 01/01/25 to 01/21/25 MAR and physician orders were reviewed, and the following was identified: The resident had orders for the following PRN medications for constipation: * Milk of magnesia; * Polyethylene glycol; and * Senna. The MAR lacked instructions to unlicensed staff for which PRN medication to administer first, second, and third. During an interview at 10:40 am on 01/22/25, Staff 4 (LPN) confirmed there were no parameters for the PRN bowel medications. The need to ensure resident-specific parameters and instructions for PRN medications was discussed with Staff 1 (ED) on 01/24/25. She acknowledged the findings.

1. Nursing reviewed Resident #3’s lidocaine orders and coordinated with the provider for the plan of care. MAR was updated to reflect any changes. Resident #4’s MAR reflect PRN parameters for fiber-lax and milk of magnesia including which medication to administer first for constipation. Resident #5 MAR reflects PRN parameters for Fleet glycerin suppository, enema, and milk of magnesia and which medication to administer first for constipation. Resident #5’s MAR was updated with PRN parameters for tramadol and acetaminophen and which to administer first for pain. Resident #2’s MAR was updated with PRN parameters for milk of magnesia, polyethylene glycol and senna and includes what order to administer medications for constipation. RN and LPN will review PRN parameters for all PRN pain medications reviewed during survey and modify as needed based on resident’s use, including coordination with provider for any changes. 2. All changes in orders will be reviewed through the three-check system. PRNs with multiple diagnoses will be reported to nursing for review of PRN parameters and which order to give them in. PRN parameters will be written by RN or provider, or LPN with RN oversight. Inservice was conducted with med staff regarding the third check system and notifying nursing of any changes to PRN medication orders or missing PRN parameters. 3. Routinely and timely; with new PRN medication orders; Quarterly with physician order review 4. Registered Nurse, Licensed Practical Nurse with Registered Nurse oversight

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure there were resident-specific parameters for PRN medications on the MAR for 3 of 3 sampled residents (#s 8, 9, and 11) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 9 was admitted to the facility in 03/2025 with diagnoses including polyneuropathy and a history of repeated falls. The resident’s 04/01/25 through 05/07/25 MARs and physician orders were reviewed. The resident had orders for the following: * Acetaminophen 500 mg, 1 tablet every 4 hours as needed for pain; and * Acetaminophen ER 650 mg, 1 tablet 3 times a day as needed for pain. There were no resident-specific parameters instructing staff of the order of administration of these PRN medications. The need to ensure PRN medications had resident-specific parameters was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (Resident Services Director), and Staff 22 (LPN / Wellness Director) on 05/09/25 at 12:40 pm. They acknowledged the findings. 2. Resident 8 was admitted to the facility in 09/2024 with diagnoses including dementia and Type 2 diabetes. The resident’s MAR, dated 04/01/25 through 05/07/25, and physician’s orders were reviewed. The following was identified: a. The resident had a signed physician’s order for the application of hydrocortisone 2.5% cream to be applied as a “thin layer to reddened area on feet for 14 days, then stop for at least 7 day[s]. Able to resume pattern if needed.” The treatment had been occurring continuously for greater than 35 days. The parameters in the resident’s MAR did not include resident specific instructions on when to stop or restart the treatment. b. The resident had two PRN medications for pain which did not both include resident-specific parameters for administration: *Acetaminophen 500 mg every 6 hours; and *Celexoib 200 mg at bedtime. The need to ensure the MAR was accurate and that PRN medications included resident-specific parameters and instructions for administration was reviewed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (Resident Services Director) and Staff 22 (LPN/Wellness Director) on 05/09/25 at 1:10 pm. They acknowledged the findings. 3.Resident 11 was admitted to the facility in 05/2023 with diagnoses including major depressive disorder and hypertension. The resident’s MAR, dated 04/01/25 through 05/07/25, and physician’s orders were reviewed. The following was identified: a. The resident had an order for mucus relief tablet, ER 600 mg once per day. On 04/22/25, 04/24/25 and 04/25/25 the medication was noted to be “not available”, “do not have in cart” and “pharmacy states in process”. However, the medication was documented as administered three times between 04/22/25 and 04/25/25. In an interview on 05/09/25 at 9:30 am, Staff 25 (MT) confirmed that the medication was not available on the dates it was documented as administered between 04/22/25 and 04/25/25. b. The resident had two PRN medications for pain which did not include resident-specific parameters for administration: *Acetaminophen ER 650 mg; and *Aspercreme 10%. The need to ensure the MAR was accurate and that PRN medications included resident-specific parameters and instructions for administration was reviewed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (Resident Services Director) and Staff 22 (LPN/Wellness Director) on 05/09/25 at 1:10 pm. They acknowledged the findings.

1. Resident 9 MAR will be updated with resident-specific parameters for all prescribed PRN medications including directions on order of administration for PRNs with same diagnosis. Resident 8 prescribing provider will be notified regarding hydrocortisone cream applied outside of order, and for clarification on further administration. MAR will reflect directions received. Resident 8 MAR will be updated with resident-specific parameters for all prescribed PRN medications including directions on order of administration for PRNs with the same diagnosis. Resident 11 provider will be notified of medication not administered per order, medications not available, yet documented as administered. From this date forward staff to accurately document medication administration. Training was conducted with Medication associates on 5/28/25, regarding accurate documention, and community process for following up with pharmacy to ensure medication is available. 2. PRN parameters are reviewed during the three check system. Licensed staff participate in the three check system. Review of the eMAR dashboard. The eMAR dashboard tracks end dates, medications waiting for delivery, medication refusals. 3. Every other week. 4. WD, AWD, RN, RSD.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by:

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: ?Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) was updated no less than quarterly for 46 of 76 residents. Findings include, but are not limited to: During the acuity interview at 12:00 pm on 01/21/25, Staff 1 (ED) confirmed the facility census was at 76 residents. The facility’s ABST data and posted staffing plan were reviewed at 11:52 am on 01/22/25. The ABST data for 46 of 76 residents did not show documented evidence of being updated at least quarterly. During an interview at 11:24 am on 01/23/25, Staff 3 (Resident Services Director) stated the facility process for updating the ABST included to update it at the same time the service plan was being updated. No additional documentation was provided to show the ABST for the above residents had been updated at least quarterly. The need to ensure residents’ ABST was updated no less than quarterly was discussed with Staff 1 on 01/24/25. She acknowledged the findings.

1. All residents identified in the survey lacking quarterly updated ABST questionnaires, were updated to reflect the current time it takes to complete tasks related to their care and staff time needed to accomplish care needs. 2) The ABST will be reviewed timely and upon every resident quarterly service plan update and will reflect the current needs of the resident. 3) Quarterly; Change of condition 4) Reisdent Services Director, Wellness Director and Executive Director

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) evaluation was updated with a significant change of condition for 3 of 3 sampled residents (#s 9, 10 and 11) and failed to ensure documentation of consistently staffing to meet or exceed the posted staffing plan. This is a repeat citation. Findings include, but are not limited to: During the acuity interview on 05/07/25, the facility provided a resident roster which identified 69 residents. 1. The facility’s ABST data was retrieved at 11:05 am on 05/07/25 and reviewed during the survey 05/07/25 through 05/09/25. The following was revealed: The ABST for three sampled residents, #’s 9, 10 and 11, had not been updated after they had a significant change of condition. 2. The facility’s posted staffing plan was documented as last updated on 04/22/25. The facility’s schedule dated 04/25/25 through 05/07/25 was reviewed. The following was identified: The posted staffing plan for the facility was as follows: * Day shift: 7 CG, 2 MT and one shower aide (totaling 9.75 care staff); * Swing shift: 6 CG, 2 MT and one shower aide (totaling 8.25 care staff); and * Night shift: 3 CG, 1 MT. The facility failed to schedule staff per the posted staffing plan for a total of 23% of shifts during the reviewed time period. The need to ensure residents’ ABST evaluations were updated with significant changes of condition and the need to ensure consistent staffing to meet or exceed the posted staffing plan was reviewed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (Resident Services Director) and Staff 22 (LPN/Wellness Director) on 05/09/25 at 1:10 pm. They acknowledged the findings.

1. For residents 9,10, and 11, the ABST will be updated to reflect residents current needs and updated, posted staffing plan. The staff schedule will be updated to ensure it meets or exceeds the posted staffing plan. 2. The ABST will be updated for all changes in condition. Posted staffing plan and staff schedule will be updated to meet or exceed posted staffing plan. 3. With each significant change of condition if indicated. 4. RSD, WD, AWD, ED.

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

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable 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 staff (#s 14, 15, and 18) completed all pre-service orientation training requirements prior to beginning their job duties. Findings include, but are not limited to: Staff training records were reviewed at 8:31 am on 01/24/25 with Staff 3 (Resident Services Director) and Staff 20 (Business Office Manager). The following was identified: There was no documented evidence Staff 14 (Dining Associate), hired 09/16/24, Staff 15 (CG), hired 10/23/24, and Staff 18 (CG), hired 11/20/24, completed pre-service orientation training in one or more of the following areas: * Abuse reporting requirements; * Infectious disease prevention; * Fire safety and emergency procedures; * Written job description; and * Home and community-based services. The need to ensure staff completed all required pre-service orientation training prior to beginning job responsibilities was discussed on 01/24/25 with Staff 1 (ED). She acknowledged the findings.

1) All associate files were audited for required pre-service training, including abuse reporting requirements, infectious disease prevention, fire safety and emergency procedures, written job description, home and community-based services. Any outstanding training will be completed by 3/25/25. 2) From this date forward, all new hires will complete the required pre-service training before performing job duties. 3) Upon completion of training, before performing job duties; quarterly 4) Resident Services Director, Wellness Director, Business Office Manager

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by:

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 demonstration of knowledge and performance in any assigned job duty within the first 30 days of hire for 2 of 2 newly hired staff (#s 15 and 18) whose training records were reviewed. Findings include, but are not limited to: Staff training records were reviewed at 8:31 am on 01/24/25 with Staff 3 (Resident Services Director). The following was identified: There was no documented evidence Staff 15 (CG), hired 10/23/24, and Staff 18 (CG), hired 11/20/24, demonstrated competency within the first 30 days of hire in one or more of the following areas: * Changes associated with normal aging; * Identification, documentation, and reporting changes of condition; and * Conditions that require assessment, treatment, observation, and reporting. The need to ensure newly hired staff demonstrated knowledge and performance in assigned job duties within the first 30 days of hire was discussed with Staff 1 (ED) on 01/24/25. She acknowledged the findings.

1) Associate files were audited for verification of 30-day demonstration of competency. Files lacking 30-day demonstrated competency will be completed to include training that meets the requirement including: changes associated with normal aging; identification, documentation, and reporting changes of condition; and conditions that require assessment, treatment, observation, and reporting. 2) Upon hire, associates will be assigned all training required to be completed by the 30 day mark. The Associate’s file will be reviewed prior to 30-day mark, to ensure completion. Associates lacking completed training by day 30, will be removed from job duties until training is completed. 3) Prior to 30 days, quarterly. 4) Resident Services Director, Wellness Director, Business Office Manager

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:

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 fire drills were conducted according to Oregon Fire Code and fire and life safety instruction to staff was provided on alternate months. Findings include but are not limited to: Six months of fire drill records were reviewed on 01/23/25 and revealed the following: a. Fire drills lacked documentation of one or more of the following components: * Date and time of day; * Location of simulated fire origin; * The escape route used; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Evacuation time period needed; and * Number of occupants evacuated. In an interview on 01/23/25 at 10:40 am, Staff 8 (Plant Operations Director) acknowledged the documentation lacked one or more of the required components. b. The facility failed to provide fire and life safety instruction to staff on alternate months. In an interview on 01/23/25 at 10:40 am, Staff 8 confirmed staff were not provided fire and life safety instruction on alternating months. Staff 1 (ED) confirmed on 01/22/25 the facility’s lack of fire and life safety instruction to staff on alternating months. The need to ensure fire drills were conducted according to Oregon Fire Code with all required components documented and fire and life safety instruction to staff was provided on alternating months was discussed with Staff 1, Staff 3 (Resident Services Director) and Staff 4 (LPN) on 01/24/25 at 11:20 am. They acknowledged these findings.

1. The Plant Operations Director and Executive Director reviewed the regulation to ensure comprehension of the rule, specifically regarding the frequency of drills and training, alternating every other month, and that the drill records must contain all of the essential components including date and time, location of simulated fire origin, the escape route used, problems encountered and comments related to residents who resisted or failed to participate in the drills, the evacuation time period needed, and the number of occupants evacuated. Fire Life Safety Training was conducted in January to account for January’s training. 2. The system was corrected by the creation of a schedule to ensure there is a plan in place with a plan in place for when Fire Life Safety training takes place, as well as the topic for that month, and alternating months will include an unannounced fire drill. 3. Monthly 4. Plant Operations Director and Executive 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 fire drills were conducted and documented according to Oregon Fire Code. This is a repeat citation. Findings include but are not limited to: Fire drill records from 03/25/25 through 05/07/25 were reviewed and revealed the following: Fire drills lacked documentation of the following components: * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Evacuation time period needed; and * Number of occupants evacuated. During an interview on 05/07/25 at 11:34 am Staff 1 (Executive Director) and Staff 8 (Plant Operations Director) stated that no residents were evacuated during the reviewed fire drills because no residents were in the hallway adjacent to the fire. Staff 8 stated that the facility currently did not evacuate residents from their rooms to a designated point of safety during a fire. The need to ensure fire drills were conducted according to Oregon Fire Code with all required components documented and fire and life safety instruction to staff was provided on alternating months was reviewed with Staff 1, Staff 2 (RN), Staff 3 (Resident Services Director) and Staff 22 (LPN/Wellness Director) on 05/09/25 at 1:10 pm. They acknowledged the findings.

1. Fire drills will be conducted according to Oregon code, focused on addressing all of the required components, including: problems encountered and commenents relating to resident who resisted or failed to participate in the drills; evacuation time period needed; and number of occupants evacuated. In-service will be conducted regarding when to evacuate a resident and designated points of safety. 2. The system will be corrected by highlighting these 3 areas on the fire drill record. Ensuring correct form for documentation is utilized. 3. Monthly. 4. POD, ED.

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 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure each resident was 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 a fire. Findings include but are not limited to: Resident fire and life safety training records were reviewed on 01/24/25 and revealed multiple unsampled residents did not receive fire and life safety instruction within 24 hours of admission or annually. In an interview on 01/23/25 at 10:55 am, Staff 8 (Plant Operations Director) confirmed he was “behind” on instruction to residents at move-in and annually. On 01/24/25 at 09:28 am, Staff 1 (ED) confirmed the facility had not been educating residents in fire and life safety instruction since 11/2024. The need to ensure each resident was 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 a fire was discussed with Staff 1, Staff 3 (Resident Services Director) and Staff 4 (LPN) on 01/24/25 at 11:20 am. They acknowledged these findings.

1. Training was completed for all resident's who were not included in a previous 24-hour move in training or annual review of Fire & Life Safety training, and completed training. 2. The Fire & Life Safety training form will be included in the new resident welcome packet and will be completed with other “new resident paperwork”. The binder will be audited monthly to ensure all training; within 24 hours of move-in and annually, is conducted as needed. 3. Monthly 4. Plant Operations Director and Executive Director

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

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 interview and record review, it was determined the facility failed to ensure the re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C231, C270, C305, C310, C363 and C420.

1. Refer to plan of correction for C231, C270, C305, C310, C363, and 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 (7)(b-d) House Keeping and Sanitation (b) HOUSEKEEPING AND SANITATION.(A) An ALF must have a secured janitor closet for storing supplies and equipment, with a floor or service sink.(B) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.(c) LAUNDRY FACILITIES. Laundry facilities may be located to allow for both resident and staff use when a time schedule for resident-use is provided and equipment is of residential type.(A) If the primary laundry facility is not suitable for resident-use, an ALF must provide separate resident laundry facilities.(B) Laundry facilities must be separate from food preparation and other resident-use areas.(C) On-site laundry facilities, used by staff for facility and resident laundry, must have capacity for locked storage of chemicals and equipment.(D) An ALF must provide covered or enclosed clean linen storage that may be on shelves or carts. Clean linens may be stored in closets outside the laundry area.(E) The wall base of the laundry facilities must be continuous and coved with the floor, tightly sealed to the wall and constructed without voids that may harbor insects or moisture.(d) SOILED LINEN PROCESSING. For the purpose of this rule, "soiled linens and soiled clothing," means linens or clothing contaminated by an individual's bodily fluids (for example, urine, feces, and blood).(A) There must be a separate area with closed containers that ensure the separate storage and handling of soiled linens and soiled clothing. There must be space and equipment to handle soiled linen and soiled clothing processing needs that is separate from regular linen and clothing.(B) Arrangement must provide a one-way flow of soiled linens and soiled clothing from the soiled area to the clean area and preclude potential for contamination of clean linens and clothing.(C) The soiled linen area must include a flushing rim clinical sink with a handheld rinsing device and a hand wash sink or lavatory.(D) When washing soiled linens and soiled clothing, washers must have a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant is used.(E) Personnel handling soiled laundry must be provided with waterproof gloves.(F) Covered or enclosed clean linen storage must be provided and may be on shelves or carts. Clean linens may be stored in closets outside the laundry area.(G) The wall base of the laundry facilities must be continuous and coved with the floor, tightly sealed to the wall and constructed without voids that may harbor insects or moisture. This Rule is not met as evidenced by: ?Based on observation and interview, it was determined the facility failed to ensure washers had a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant was used when washing soiled linens. Findings include, but are not limited to: The facility soiled linen room was toured on 01/23/25 and interviews with staff were completed and revealed the following: During interviews with Staff 6 (CG) and Staff 18 (CG) on 01/22/25 and 01/24/25, respectively, they stated incontinent linen was bagged up, taken downstairs to the incontinent laundry room, rinsed in the flushing rim sink, and washed in the small washer with detergent added by pressing a button. The washing process was confirmed by Staff 21 (Environmental Services Director) on 01/23/25 at 10:03 am. On 01/24/25 at 08:56 am Staff 21 confirmed the detergent used for washing incontinent laundry did not have a chemical disinfectant added. Staff 8 (Plant Operations Director) and this surveyor took the temperature of the water line feeding into the incontinent laundry room on 01/23/25 at 10:17 am. Over two separate readings, the water reached 120 degrees F and 121.3 degrees F, or nearly 20 degrees less than the required 140 degrees F needed when washing soiled linens without a chemical disinfectant. The need to ensure washers had a minimum rinse temperature of 140 degrees F unless a chemical disinfectant was used was reviewed with Staff1 (ED), Staff 3 (Resident Services Director) and Staff 4 (LPN) on 01/24/25 at 11:20 am. They acknowledged these findings.

1. To immediately correct the rule, a disinfectant, Oxi Clean, was purchased and put in place. 2. The system was corrected so this violation will not happen again by educating all housekeeping associates and care associates that all incontinent laundry must include the Oxi Clean disinfectant in every load. A tracking tool was put in place to ensure that every time the incontinent laundry is washed, the associate completing the load will initial and date, verifying the Oxi Clean was used. 3. Frequently 4. Environmental Services Director and Plant Operations Director

OAR 411-054-0300 (7)(b-d) House Keeping and Sanitation (b) HOUSEKEEPING AND SANITATION.(A) An ALF must have a secured janitor closet for storing supplies and equipment, with a floor or service sink.(B) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.(c) LAUNDRY FACILITIES. Laundry facilities may be located to allow for both resident and staff use when a time schedule for resident-use is provided and equipment is of residential type.(A) If the primary laundry facility is not suitable for resident-use, an ALF must provide separate resident laundry facilities.(B) Laundry facilities must be separate from food preparation and other resident-use areas.(C) On-site laundry facilities, used by staff for facility and resident laundry, must have capacity for locked storage of chemicals and equipment.(D) An ALF must provide covered or enclosed clean linen storage that may be on shelves or carts. Clean linens may be stored in closets outside the laundry area.(E) The wall base of the laundry facilities must be continuous and coved with the floor, tightly sealed to the wall and constructed without voids that may harbor insects or moisture.(d) SOILED LINEN PROCESSING. For the purpose of this rule, "soiled linens and soiled clothing," means linens or clothing contaminated by an individual's bodily fluids (for example, urine, feces, and blood).(A) There must be a separate area with closed containers that ensure the separate storage and handling of soiled linens and soiled clothing. There must be space and equipment to handle soiled linen and soiled clothing processing needs that is separate from regular linen and clothing.(B) Arrangement must provide a one-way flow of soiled linens and soiled clothing from the soiled area to the clean area and preclude potential for contamination of clean linens and clothing.(C) The soiled linen area must include a flushing rim clinical sink with a handheld rinsing device and a hand wash sink or lavatory.(D) When washing soiled linens and soiled clothing, washers must have a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant is used.(E) Personnel handling soiled laundry must be provided with waterproof gloves.(F) Covered or enclosed clean linen storage must be provided and may be on shelves or carts. Clean linens may be stored in closets outside the laundry area.(G) The wall base of the laundry facilities must be continuous and coved with the floor, tightly sealed to the wall and constructed without voids that may harbor insects or moisture. This Rule is not met as evidenced by: