OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. Findings include, but are not limited to: During the re-licensure survey, conducted 03/03/25 through 03/06/25, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations. Refer to the deficiencies identified in the report.

1. The Administrator or designee oversees the daily operations of the community. Please refer to citations C: 200, 231, 260, 262, 270, 280, 303, 305, 310, 361, 362, 363, 370, 372, 374, 420, 610, 613. 2. Please refer to citations C: 200, 231, 260, 262, 270, 280, 303, 305, 310, 361, 362, 363, 370, 372, 374, 420, 610, 613. 3. Daily, weekly, monthly. 4. The Administrator.

OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals. This Rule is not met as evidenced by:

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the residents right to be given informed choice and opportunity to select food choices for 1 of 1 sampled resident (#4) who had a modified diet. Findings include, but are not limited to: Resident 4 moved into the facility in 11/2024 with diagnosis including chronic obstructive pulmonary disease (COPD), respiratory failure, spastic hemiplegia, and dysphagia. The resident was identified in the acuity interview to receive a modified diet. Meal observations were completed and interviews with staff and the resident were conducted from 03/03/25 through 03/06/25, and identified the following: On 03/03/25, Resident 4 was observed to receive a bowl that contained cream colored textured food and stated s/he “[thought] it [was] chicken” and s/he was “tired of chicken” or “whatever this is.” On 03/04/25, Resident 4 stated s/he ordered “french toast” for breakfast, however staff told the resident they “couldn’t have french toast” and was served cream of wheat. The resident was served pureed chicken for lunch and stated s/he ordered “something else and this is what [s/he] got”. On 03/04/25, Staff 21 (Dietary Aide) stated the resident requested food s/he cannot have so staff prepare something else. On 03/05/25, Resident 4 stated s/he “[checked] multiple items on the menu” and “only [got] one thing”. Staff 21 confirmed the resident did not receive what s/he ordered for lunch and instead was provided pureed chicken. On 03/06/25, Resident 4 was served pureed barbeque chicken for lunch and was not given informed choice or opportunity to select his/her food choices. The need to ensure residents were given informed choice and opportunity to select food choices was reviewed with Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN) on 03/06/25 at 1:27 pm. They acknowledged the findings.

1. An Individual Nutrition/Hydration Plan form has been developed for Resident 4. The Dietary Director interviewed the resident to identify the residents preferences. The dining staff and care staff have been in-serviced on what is a pureed diet. Consultant provided an example of pureed diet for training.The administrator has been observing meal service and the pureed food provided. The diet order is in place and posted in the kitchen. 2. All diet orders will be reviewed and verified. Dining staff and care staff training on the different types of diets and expectations. The diet resources have been placed in kitchen for easy reference. Diet training will happen with onboarding for dining staff and care staff. Dining manager is scheduled to do rounds to ensure the food is served as ordered. Feedback will be provided from residents individually, through food committee and town hall. 3. Daily, weekly, monthly. 4. Administrator and Dietary Services Director

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by:

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 promptly investigate incidents to rule out abuse or neglect and report incidents to the local Seniors and People with Disabilities (SPD) office, if abuse or neglect could not be ruled out, for 1 of 1 sampled resident (#4) who had a puree diet. Findings include, but are not limited to: Resident 4 moved into the facility in 11/2024 with diagnoses including chronic obstructive pulmonary disease (COPD), respiratory failure, spastic hemiplegia, and dysphagia. Additionally, the resident was admitted with a puree diet. The resident’s clinical record including, observation notes dated 12/03/24 through 03/03/25, and temporary service plans were reviewed. The following was identified: * 12/07/24 - “...resident was eating [solid food] in [his/her] room and [had] choking issues”; and * 12/29/24 - “resident was choking in the dining room cause the kitchen gave her mechanical soft instead of puree”. On 03/06/25 at 11:40 pm, Staff 3 (Wellness Director) stated there was no documented evidence either event was investigated to rule out abuse or neglect. On 03/06/25 at 12:27 pm, Staff 1 (ED) confirmed the events were not investigated to rule out abuse or neglect and the event on 12/07/24 was not reported to local SPD. Staff 1 provided documentation the event on 12/29/24 was reported on 03/05/25, after survey requested documentation. The need to promptly investigate injuries of unknown cause with all required components and report the incidents to the local SPD office if abuse or neglect could not be ruled out, was discussed with Staff 1, Staff 3, and Staff 25 (RN) on 03/06/25 at 1:27 pm. They acknowledged the findings.

1.Resident 4 12/29/2024 incident has been investigated and reported to APS. The APS report was submitted during the survey on 3/5/2025. Refer to C200. The dining staff and care staff have also been in-serviced on reporting/indentifying abuse and neglect, how to respond to choking and abdominal thrust. 2. Refer to C200. Incidents reviewed daily by the clinical team during morning stand-up. Investigations completed within 24 hours of incident and reported to local SPD when unable to rule out abuse, neglect or injuries of unknown cause. Staff training completed on reporting/identifying abuse and neglect, how to respond to choking and abdominal thrust. 3. Daily, monthly. 4. Administrator, WD

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by:

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were readily available to staff, reflective of residents' current care needs, provided clear directions to staff regarding the delivery of services, and the facility administrator was responsible for ensuring the implementation of services for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 03/2020 with diagnoses including chronic diastolic (congestive) heart failure, malignant neoplasm of unspecified ovary, and shortness of breath. Additionally, the resident’s hospital discharge notes included a diagnosis of chronic obstructive pulmonary disease (COPD). Interviews with the resident and facility staff were conducted. The current service plan dated 01/24/25 was reviewed. Resident 1's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Instructions on edema management; * Smoking; * Instructions on signs and symptoms of depression to report while on anti-depressant therapy; * Oxygen equipment precautions, instructions for proper maintenance, and how to monitor for safety; * Non-pharmaceutical interventions for pain, including how a person expresses pain or discomfort; * Instructions on proper maintenance of nebulizer used for breathing therapy; * Instructions for aspiration precautions and interventions while choking; * Number of staff needed to assist with emergency evacuations; * Instructions on to whom to report weight gain or loss; * Instructions on fall prevention; * Skin integrity and instructions on to whom to report skin impairments; * Incorrect reference to existence of a chemotherapy port; * Incorrect reference to not having a dog; and * Number of staff needed to assist with transfers to wheelchair. The facility stores resident care plans in an electronic database and makes available to staff a portion of the service plans, referred to by the facility as Active Cares, by storing them in a binder located in the staff break room. Therefore, Resident 1’s full current service plan was not included in the binder and not available to facility staff at the time of the survey. The need to ensure service plans were readily available to staff, reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (ED), Staff 25 (RN), and Staff 3 (Wellness Director) on 03/06/25 at 1:28 pm. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 12/2021 with diagnoses including opioid dependence and major depressive disorder. The service plan dated 02/04/25, temporary service plans and observation notes dated 12/04/24 through 03/01/25 were reviewed. Interviews with care staff were completed. The resident's service plan was not reflective and/or failed to provide clear instruction to staff, and/or the facility administrator was responsible for ensuring the implementation of services in the following areas: * Oral care; * Behavioral monitoring; * Safety checks; and * Safety plan. The service plan instructed staff to provide behavior monitoring daily at 5:00 am, 1:00 pm and 9:00 pm. Review of the service plan “Task Administration Record” was completed from 12/01/24 through 02/28/25 and revealed behavior monitoring took place six times during the time period reviewed. In an interview with Staff 18 (MT) on 03/06/25, at 11:10 am, it was confirmed that the behavioral monitoring was not being done daily. The need to ensure service plans were reflective of the resident's care needs and provided clear instruction to staff was discussed with Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN) on 03/06/25 at 3:15 pm. The findings were acknowledged. 3. Resident 3 was admitted in 09/2024 with diagnosis including diabetes, cardiomegaly, and kidney disease. The service plan dated 02/28/25, temporary service plans and observation notes dated 12/04/24 through 03/01/25 were reviewed. Interviews with care staff were completed. The resident's service plan was not reflective, failed to provide clear instruction to staff, and/or the facility administrator was responsible for ensuring the implementation of services in the following areas: * Wound care and precautions; * Home health services; * Fall interventions; and * Catheter care. A progress note dated 12/25/24 documented “resident’s catheter bag was not emptied on day shift, resident told me day shift kept telling him/her they were busy and couldn’t empty it, or they would come back to empty it but never did”. Review of the service plan “Task Administration Record” for December 2024 indicated Resident 3’s catheter bag was to be emptied twice each shift, documented when completed, and if there was no urine output to report to the nurse. The task was left blank 89 times in December 2024. The need to ensure service plans provided clear instruction to staff and were followed was reviewed on 03/05/25 with Witness 1 (RN Consultant) and on 03/06/25 with Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN). They acknowledged the findings. 4. Resident 4 moved into the facility in 11/2024 with diagnosis including chronic obstructive pulmonary disease (COPD), respiratory failure, spastic hemiplegia, and dysphagia. The current service plan dated 02/06/25 and temporary service plans were reviewed, observations were made, and interviews with the resident and facility staff were conducted. The following was identified: a. The resident’s current service plan, dated 02/06/25, was not available to staff. b. The resident’s service plan lacked resident specific instruction and/or was not reflective of the resident’s current status in the following areas: * Use of Hoyer including the risks, benefits, and safety instructions; * Use of hospital bed and side rails including the risks, benefits, and safety instructions; * Use of assistive devices including contracture cushion for left hand and leg brace; * Incontinent care including incontinent checks and resident specific instruction; * Bowel care instruction and monitoring; * Behavior interventions including frequency of checks; * Instruction relating to “promptly answer call lights”; * Resident specific bathing instruction including use of bed for bed baths; * Use of “puffy socks” and pillows while in wheelchair; * Instruction relating to taking all vitals twice daily; * Use of resident’s personal beverage cups and straws including cleaning instruction; and * Resident’s current smoking status. The need to ensure the resident’s service plan was available to staff, provided resident specific instruction, and was reflective of the resident’s current status, was reviewed with Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN) on 03/06/25 at 1:27 pm. They acknowledged the findings.

1. Resident 1 (CB) deceased as of 3/7/2025. Resident 2 (TD), 3 (SG) (completed) and 4 (CM) service plans will be updated to reflect resident's current status and needs, provide clear resident specific instructions to staff regarding delivery of services and implementation of services by alleged compliance date. Service plans placed in service plan binder, located in the employee breakroom and is available to staff. All other service plans are under review for accuracy and will be completed by the alleged compliance date. The binder also includes any pertinent instructions from hospital, home health, hospice, behavioral support, and community nurse. Care staff and Med Techs in-serviced on following care plans, EMAR and proper documentation. 2. All service plans are printed, kept in a service plan binder and availble to staff. Service plans are printed any time a TSP, Signficant change of condition, or any other change is made to the service plan. An acknowledgement form for staff to sign will be kept with service plans. RCC and WD review dashboard to EMAR daily to ensure proper documentation and care plans being followed. 3. Daily, weekly, monthly. 4. Administrator, WD, RCC

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

OAR 411-054-0036 (5) Service Plan: Service Planning Team (5) SERVICE PLANNING TEAM. The service plan must be developed by a Service Planning Team that consists of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident. Involved family members and case managers must be notified in advance of the service-planning meeting.(a) As applicable, the Service Planning Team must also include:(A) Local APD or AAA case managers and family invited by the resident, as available.(B) A licensed nurse if the resident shall need, or is receiving nursing services or experiences a significant change of condition as required in 411-054-0045(1)(f)(D) (Resident Health Services).(C) The resident's physician or other health practitioner.(b) Each resident must actively participate in the development of the service plan to the extent of the resident's ability and willingness to do so. If resident participation is not possible, documentation must reflect the facility's attempts to determine the resident's preferences. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who was familiar with, or who was going to provide services to the resident for 4 of 4 sampled residents (#s 1, 2, 3, and 4). Findings include, but are not limited to: Resident 1, 2, 3 and 4's most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans. The need to ensure service plans were developed by a Service Planning Team was reviewed with Staff 1 (ED), Staff 25 (RN), and Staff 3 (Wellness Director) on 03/06/25 at 1:28 pm. They acknowledged the findings. No further information was provided.

1. Refer to C260. Service plans will be developed and reviewed for residents 2, 3, and 4 by a Service Planning Team that consists of the resident, legal representative (if applicable) any person of the resident's choice, Administrator or designee and one other staff person familiar with services provided to the resident by alleged compliance date. 2. Going over upcoming service plan review and due date report from ECP dashboard during daily stand-up clinical meeting. A tracking sheet of service conferences will be maintained. Caseworkers will receive monthly notifications about upcoming service conferences and are encouraged to attend if possible. 3. Daily, weekly, monthly. 4. Administrator, WD, RCC

OAR 411-054-0036 (5) Service Plan: Service Planning Team (5) SERVICE PLANNING TEAM. The service plan must be developed by a Service Planning Team that consists of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident. Involved family members and case managers must be notified in advance of the service-planning meeting.(a) As applicable, the Service Planning Team must also include:(A) Local APD or AAA case managers and family invited by the resident, as available.(B) A licensed nurse if the resident shall need, or is receiving nursing services or experiences a significant change of condition as required in 411-054-0045(1)(f)(D) (Resident Health Services).(C) The resident's physician or other health practitioner.(b) Each resident must actively participate in the development of the service plan to the extent of the resident's ability and willingness to do so. If resident participation is not possible, documentation must reflect the facility's attempts to determine the resident's preferences. 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 observation, interview, and record review, it was determined the facility 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, and document progress until the condition resolved for 4 of 4 sampled residents (#s 1, 2, 3, and 4) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 03/2020 with diagnoses including chronic diastolic (congestive) heart failure, malignant neoplasm of unspecified ovary, and shortness of breath. Additionally, the resident’s hospital discharge notes included a diagnosis of chronic obstructive pulmonary disease (COPD). Clinical records, including the current service plan, TARs from 12/01/24 through 02/28/25, observation notes from 12/03/24 through 03/03/25 were reviewed, and interviews with the resident and facility staff were conducted. The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved: * 12/06/24: return to the facility after ER visit related to exacerbation of chronic obstructive pulmonary disease (COPD); * 01/08/25: return to the facility after oncology visit and started new medication Cyclophosphamide 50mg (for malignant neoplasm); * 01/16/25: return to the facility after ER visit related to chest pain and shortness of breath; * 01/19/25: choking episode; * 02/08/25: blood pressure 80/53 mm/Hg (outside normal parameters); * 02/10/25: blood pressure 87/52 mm/Hg (outside normal parameters); * 02/15/25: smoking in the room; * 02/17/25: blood pressure 67/36 mm/Hg (outside normal parameters); * 02/19/25: no bowel movement for three consecutive days; * 02/21/25: blood pressure 84/51 mm/Hg (outside normal parameters); * 02/23/25: returned from ER with diagnosis of brain transient ischemic attack (TIA) and COPD exacerbation; and * 02/26/25: blood pressure 86/49 mm/Hg (outside normal parameters). The need to ensure the facility determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was reviewed with Staff 1 (ED), Staff 25 (RN), and Staff 3 (Wellness Director) on 03/06/25 at 1:28 pm. They acknowledged the findings. 2. Resident 2 moved into the facility in 12/2021 with diagnoses including opioid dependence and major depressive disorder. The resident’s clinical record, including the current service plan dated 02/04/25, observation notes dated 12/01/24 through 03/01/25, alert charting notes dated 12/16/24 through 02/25/25, Task Administration Record dated 12/01/24 through 02/28/25, temporary service plans were reviewed, and facility staff were interviewed. The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved: * 12/16/24: experienced a sudden loss; * 01/14/25: new medication (docusate); * 01/20/25: missed 8 am medications; * 01/26/25: unwitnessed fall; * 02/04/25: resident to resident altercation; * 02/21/25: smoking in apartment; and * 02/24/25: missed 12 pm medications. The need to ensure the facility determined and documented resident-specific actions or interventions needed for changes of condition, communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved was discussed with Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN) on 03/06/25 at 3:15 pm. The findings were acknowledged. 3. Resident 3 was admitted in 09/2024 with diagnosis including diabetes, cardiomegaly, and kidney disease. Clinical records, including the current service plan, TARs from 12/01/24 through 02/28/25, home health notes, observation notes from 12/03/24 through 03/03/25 were reviewed, and interviews with the resident and facility staff were conducted. The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved. * 12/24/24: discovery of open wound; * 12/29/24: discovery of four inch open wound and ulceration at suprapubic catheter site; * 01/09/25: discovery of a wound on head; and * 01/25/25: discovery of a wound on leg. On 02/28/25, an RN assessed Resident 3’s skin and identified six wounds, and additional wounds covered with dressings. On 03/04/25, Witness 1 (RN Consultant) reviewed Resident 3’s medical record, and was not able to find documented evidence the wounds had been evaluated when discovered or had individual weekly monitoring until resolution. In interview on 03/05/25, Staff 3 (Wellness Director) acknowledged there was not consistent documented monitoring of the wounds prior to the RN assessment on 02/28/25, and the wounds were now being treated and monitored. The need to ensure the facility determined and documented resident-specific actions or interventions needed for changes of condition, communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved was reviewed on 03/05/25 with Witness 1 (RN Consultant), and on 03/06/25 with Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN). They acknowledged the findings. 4. Resident 4 moved into the facility in 11/2024 with diagnosis including chronic obstructive pulmonary disease (COPD), respiratory failure, spastic hemiplegia, and dysphagia. The resident’s clinical record, including the current service plan dated 02/06/25, observation notes dated 12/03/24 through 03/03/25, and interim service plans (ISPs) were reviewed. The following was identified: The following changes of condition lacked documentation the change of condition was identified, included resident-specific actions or interventions, and/or was monitored consistent with his/her evaluated needs through resolution: * 12/07/24: Choked on cereal in room; * 12/28/24: Missed medication; * 12/29/24: Choked in dining room, was provided incorrect texture diet; * 12/29/24: Multiple missed medications; * 01/02/25: Float heels, use pillow while in wheelchair; * 02/02/25: Painful urination; * 02/02/25: Start of antibiotics for infection; * 02/06/25: Skin condition in peri area; * 02/09/25: New redness inner thighs; * 02/26/25: Return from hospital new diagnosis; * 02/28/25: Multiple new medications; and * 03/01/25: Start taking a full set of vitals twice daily. The need to ensure residents who experienced changes of condition were monitored consistent with their evaluated needs through resolution and resident specific interventions were determined and implemented was discussed with Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN) on 03/06/25 at 1:27 pm. They acknowledged the findings.

1. Resident 1 (CB) deceased as of 3/7/2025. Service plans and TSP's will be reviewed and updated for residents 2, 3, and 4 including any COC by alleged compliance date. Alert monitoring tracking sheet also implemented. 2. Med Tech's and Care staff have been in-serviced on the use of approved Temporary Service Plan (TSP) form and when to notify RCC and Nurse using the Nurse reporting guidline form. Med Tech's in-serviced on alert charting following the Alert Charting Guidelines. WD and RCC review ECP recent notes daily and the alert monitoring tracking sheet. WD and RN keep a white board of all skin concerns and provide weekly skin/wound monitoring. Med Tech's and care staff in-serviced on when and how to report any unusual or sudden changes in residents physical or mental condition to nurse to ensure timely assessment and intervention. RN to complete Significant change of condition assessment as required per policy and OAR. 3. Daily, weekly, monthly. 4. Administrator, RN, WD, RCC

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

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an RN completed an assessment which documented findings, resident status, and interventions made as a result of the assessment for 2 of 3 sampled resident (#s 1 and 3) who experienced significant changes of condition related to loss/gain of weight. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 03/2020 with diagnoses including chronic diastolic (congestive) heart failure, malignant neoplasm of unspecified ovary, and shortness of breath. Additionally, the resident’s hospital discharge notes included a diagnosis of chronic obstructive pulmonary disease (COPD). Clinical records, including the current service plan, dated 01/24/25, TARs from 12/01/24 through 02/28/25, and physician orders were reviewed. According to the resident's TARs, the resident's weight was scheduled to be taken on the third Wednesday of each month. The following weights were recorded by the facility: * 09/18/24 – 106.5 pounds; * No weight was recorded in 10/2024; * 11/26/24 – 118.0 pounds; * 12/30/24 – 118.5 pounds; * 01/15/25 – 119.0 pounds; * 01/19/25 – 0 pounds; and * 02/19/25 – 119.0 pounds. The resident experienced a 12.0 pound weight gain, or 10.12% of his/her total body weight, in three months (09/18/24 through 12/30/24). This represented a significant change of condition. There was no documented evidence the facility RN conducted assessments which included documentation of findings, resident status, and interventions made as a result of the assessments. The resident refused to be weighed and ate independently in his/her room. The need to ensure an RN assessment was completed for all residents who experienced a significant change of condition was reviewed with Staff 1 (ED), Staff 25 (RN), and Staff 3 (Wellness Director) on 03/06/25 at 1:28 pm. They acknowledged the findings. 2. Resident 3 was admitted in 09/2024 with diagnosis including diabetes, cardiomegaly, and kidney disease. Clinical records, including the current service plan, TARs from 12/01/24 through 02/28/25, observation notes from 12/03/24 through 03/03/25 were reviewed, and interviews with the resident and facility staff were conducted. The following changes of condition were identified: a. The following weights were recorded by the facility: * 11/26/24 - 370 lbs; * 12/30/24 - 375 lbs; * 01/15/25 - 356 lbs =19 pound or 5% weight loss; and * 02/26/25 - 380 lbs = 24 pound or 6.75% weight gain. The resident experienced a 19 pound weight loss, or 5% of his/her total body weight, in 15 days (12/30/24 through 01/15/25), and a 24 pound gain, or 6.75% weight gain in one month (01/15/25 through 02/26/25). A meal observation was completed at 12:45 on 03/04/25, Resident 3 ate independently, and completed close to 100% of the meal. A second meal observation was completed on 03/05/25, Resident 3 ate approximately 75% of the meal independently. The most recent weight available for Resident 3 was taken on 02/26/25 and recorded as 380 lbs. There was no documented evaluation of the weight changes. The unexplained weight changes constituted significant changes of condition. There was no documented evidence the facility RN assessed the weight changes, including documentation of findings, resident status, and interventions made as a result of the assessments. b. On 01/13/25 Resident 3 was admitted to the hospital. Observation notes dated 01/14/25 documented: “mobility needs have changed... one person assist with all transfers and wheelchair necessity not walker”. Resident 3 returned to the facility on 01/15/25 with five medication changes, using a wheelchair instead of a walker, and requiring a one person assist with ADLs they had been previously independent with. The changes constituted a major deviation from the most recent evaluation that affected multiple areas of functioning and were not expected to be short term. There was no documented evidence the facility RN assessed the changes, including documentation of findings, resident status, and interventions made as a result of the assessments. c. On 02/13/25 Resident 3 was hospitalized. An observation note dated 02/17/25 documented “Change of Condition Assessment needed by RN due to coming back with oxygen orders of 2 liter continuous” and while at the hospital “had 10 liters of fluid removed and IV antibiotics”. A change of condition evaluation was completed by Staff 25 (RN) three days later, on 2/20/25, and documented Resident 3 had not had any hospital admissions in the past year. The need to ensure a timely and accurate RN assessment was completed for all residents who experienced a significant change of condition was reviewed with Staff 1 (ED), Staff 25 (RN), and Staff 3 (Wellness Director) on 03/06/25 at 3:28 pm. They acknowledged the findings.

1. RN completed COC evaluation and updated service plan for resident 3. 2. RN to be available on site per new position at 40hrs per week and available by phone after hours. New RN will be trained for timely and accurate review of weight monitoring in EHR system, and the new RN will be signed up to attend the OHCA Role of the Nurse class if not previously completed in the last 365 days. New WD/LPN will be trained on when to report potential COC to RN for assessment. Nurse (LPN or RN) to review all return paperwork from hospital visits (ER) or hospital admissions to determine appropriate montioring, interventions or need of COC assessment by RN for return to facility. White board monitoring system for residents who have had a recent COC to continue montioring and assessment of interventions effectiveness and return to baseline. 3. Daily, weekly, monthly. 4. Administrator, RN, WD, RCC

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

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure physician or other legally recognized practitioner orders were carried out as prescribed for 3 of 5 sampled residents (#s 3, 4, and 5) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted in 09/2024 with diagnosis including diabetes, cardiomegaly, and kidney disease. Physician orders and MARs, reviewed from 02/01/25 through 03/03/25, revealed the following medications were being administered by the facility: * Furosemide 20 mg tab (diuretic); and * Supplemental oxygen (continuous). In interview on 03/05/25, Witness 1 (RN Consultant) was unable to locate a signed order for the medications. During an interview on 03/06/25 at 11:00 am, Staff 3 (Wellness Director) was not able to locate a signed order for the medications. In interview on 03/06/25, Staff 3 stated if the signed orders could not be located, new copies of the orders would be obtained. The lack of an order for the medications was reviewed 03/06/25 with Staff 1 (ED), Staff 3, and Staff 25 (RN). They acknowledged the findings. 2. Resident 4 moved into the facility in 11/2024 with diagnosis including chronic obstructive pulmonary disease (COPD), respiratory failure, spastic hemiplegia, and dysphagia. The resident’s record was reviewed and interviews with staff were conducted and identified the resident did not have current signed physician orders. On 03/04/25 at 11:17 am, Resident 4’s signed physician orders were requested, and Staff 5 (RCC) stated the resident was in-between physicians and the facility did not have current signed orders. On 03/06/25 at 1:26 pm, Staff 3 (Wellness Director) confirmed the resident did not have current signed physician orders. The need to ensure signed physician orders were documented in the resident's facility record was reviewed with Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN) on 03/06/25 at 1:27 pm. They acknowledged the findings. 3. Resident 5 was admitted to the facility in 09/2017 with diagnoses including type 2 diabetes mellitus. Facility staff administered insulin to the resident three times daily. a. Review of Resident 5's medical record, current physician orders, dated 11/15/24, and MAR from 02/01/25 through 02/28/25 revealed Humalog suspension 100 unit/ml (to control blood glucose level) was ordered to “…inject 6 units subcutaneously two times daily at lunch and dinner. Hold if CBG is less than 80 or if resident is not eating meal.” In an interview on 03/05/25 at 12:40 pm, the resident stated s/he “usually” eats meals in the room and staff administers insulin injections prior to eating meals. The timing of administration of insulin injections was confirmed by review of the facility Med Pass history record. The insulin injections were administered prior to meal delivery times as observed by the survey team during the survey visit. During the interview on 03/05/25 at 1:07 pm, Staff 18 (MT) stated the facility does not keep track of timing or amount of food intake. b. Blood sugar checks (CBG's) were ordered before lunch and dinner (for diabetes). The physician and RN were to be notified of any CBG below 70 or above 400. There was no documented evidence the facility notified the physician of blood sugars above 400 on 17 occasions. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed Staff 1 (ED), Staff 25 (RN), and Staff 3 (Wellness Director) on 03/06/25 at 1:28 pm. They acknowledged the findings.

1. The following (a-h) have been completed. a. Complete EMAR audit to be completed by RN. Review for appropriate orders, indication, directions, interventions and administration steps for multiple orders with same indication to be evaluated. b. Nursing to review for oxygen use in facility with correlating MD order and EMAR directions. c. 90 day orders faxed to all providers for review and signatures. Tracking sheet for processing of 90 day orders maintained. Signed orders then faxed to pharmacy for update. This shall be completed on a 90 day basis by LPN, RCC or designee. d. Complete review of med room processes and box system reimplemented. Filing system reviewed for accuracy and timliness. Accurate purging system implemented to assure orders processed and filed timely. e. RCC training completed by RN for appropriate steps on processing orders, verifying accuracy and pharmacy medication check-in review 3/21/25. f. Current signed physician orders received for resident 4. g. Communication with PCP for directions on resident 5. h. Humalog directions/notifications clarified. PCP states only to notify of CBG that is above 500 or below 70. RN implemented required Question attached to CBG order for MT to indicate if PCP was notfified via Fax or call regarding above PCP parameters. Hold orders for "not eating" removed. 2. The above systems are implemented. 3 check system in place for all orders. Dashboard monitoring daily. 90 Day physician orders sent out and tracked back by RCC. Then given to the nurse for review. 3. Daily, weekly, monthly. 4. Administrator, RN, WD, RCC

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by:

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 3 of 4 sampled residents (#s 1, 3, and 4) who had documented medication and/or treatment refusals. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 11/2024 with diagnosis including chronic obstructive pulmonary disease (COPD), respiratory failure, spastic hemiplegia, and dysphagia. The resident's February MAR dated 02/01/25 to 02/28/25 and “Physician Order Sheet” dated 02/15/25 was reviewed and identified Resident 4 refused his/her scheduled Polyethylene glycol powder (for constipation) on 25 occasions. On 03/05/25 at 9:57 am, Staff 19 (MT) confirmed the lack of prescriber notification. The need to ensure the physician or other practitioner was notified when a resident refused consent to orders was reviewed with Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN) on 03/06/25 at 1:27 pm. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 03/2020 with diagnoses including chronic diastolic (congestive) heart failure, malignant neoplasm of unspecified ovary, and shortness of breath. Additionally, the resident’s hospital discharge notes included a diagnosis of chronic obstructive pulmonary disease (COPD). Resident 1's MARs from 02/01/25 through 02/28/25 and corresponding Med Pass History from 02/01/25 through 03/02/25 were reviewed. The resident's records showed the following medication and treatment refusals: * Nicotine transdermal patch (for nicotine dependence) on 20 occasions; * Trelegy Ellipta (breathing treatment) on two occasions; * Ipratropium/Albuterol (breathing treatment) on two occasions; and * Calmoceptine ointment (for skin care) on 23 occasions. There was no documented evidence the facility notified the physician or other practitioner each time the resident refused to consent to the orders. The need to ensure the facility notified the physician or other practitioner of medication and treatment refusals was reviewed with Staff 1 (ED), Staff 25 (RN), and Staff 3 (Wellness Director) on 03/06/25 at 1:28 pm. They acknowledged the findings. 3. Resident 3 was admitted in 09/2024 with diagnosis including diabetes, cardiomegaly, and kidney disease. Resident 3's MARs from 02/01/25 through 02/28/25 and corresponding Med Pass History from 02/01/25 through 03/02/25 were reviewed. The resident's records showed the following medication and treatment refusals: * Mupirocin 2% ointment (for skin care) on 19 occasions; and * Zinc Oxide 40% cream (for skin care) on 21 occasions. There was no documented evidence the facility notified the physician or other practitioner each time the resident refused to consent to the orders. The need to ensure the facility notified the physician or other practitioner of medication and treatment refusals was reviewed on 03/05/25 with Witness 1 (RN Consultant) and on 03/06/25 with Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN). They acknowledged the findings.

1. Med Techs re-instructed on daily notifications of medications refused, unless otherwise noted by the PCP. Faxes were sent to PCP's to clarify their preference of refusal notifications and if other than daily, this will be added to EMAR to prompt for notification. Company form for refusals was re-implemented and Med Techs trained on it's use 3/20/25 by RCC and RN. 2. For residents with frequent refusals- parameters for notification are requested from provider. For consistent refusals of certain medications, a request for provider review of appropriateness of continued order are sent. If refusals are deemed to be behavioral in nature, a consideration for Behavioral Support is made. 3. Daily, weekly, monthly 4. Administrator, WD, RCC

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 MARs were accurate and included resident-specific parameters and contained reasons for use for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 12/2021 with diagnoses including opioid dependance and major depressive disorder. Resident 2's MARs from 02/01/25 through 02/28/25, corresponding Med Pass History from 02/01/25 through 03/02/25, and physician orders were reviewed and revealed the following: a. The following medications lacked documented reasons for use: * Sucralfate 1 gm (for ulcers); * Donepezil 10 mg (for cognition); * Memantine HCL 10 mg (for memory); * Polyethelene glycol 17 gm (for constipation); * Secura protective 10% cream 1 gm (for skin rash); and * Metamucil 3.4 gm (for constipation). The need to ensure MARs included reasons for use was discussed with Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN) on 03/06/25 at 3:15 pm. The findings were acknowledged. b. Resident 2 was prescribed docusate sodium, Metamucil, and polyethylene glycol for constipation. There were no parameters listed on the MAR for the PRN bowel medications instructing staff which should be used first. In an interview with Staff 18 (MT) on 03/06/25, at 11:10 am, it was confirmed that the electronic MAR did not contain any additional information for staff as to which PRN bowel medication to use first. The need to ensure MARs included resident-specific parameters for all PRN medications was discussed with Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN) on 03/06/25 at 3:15 pm. The findings were acknowledged. 2. Resident 1 was admitted to the facility in 03/2020 with diagnoses including chronic diastolic (congestive) heart failure, malignant neoplasm of unspecified ovary, and shortness of breath. Additionally, the resident’s hospital discharge notes included a diagnosis of chronic obstructive pulmonary disease (COPD). Resident 1's MARs from 02/01/25 through 02/28/25, corresponding Med Pass History from 02/01/25 through 03/02/25, physician orders were reviewed and revealed the following medications lacked documented reasons for use: * Pregabalin 50mg (for nerve pain); * Midodrine 5mg (for lower blood pressure); * Ipratropium/Albuterol 0.5-2.5mg (for difficulty breathing); * Omeprazole 20mg (for gastro-esophageal reflux); * Ropinirole 1mg (for restless leg syndrome); * Trelegy Ellipta 100-62.5-25 mcg (for COPD); * Cyclophosphamide 50mg (for malignant neoplasm); * Furosemide 40mg (diuretic); * Prednisone 50mg (anti-inflammatory); * Ketotifen 0.025% (for dry eyes); and * Betameth Dip Aug 0.05% (for rash). The need to ensure MARs for each resident that the facility administers medications to include reason for use was reviewed with Staff 1 (ED), Staff 25 (RN), and Staff 3 (Wellness Director) on 03/06/25 at 1:28 pm. They acknowledged the findings. 3. Resident 3 was admitted in 09/2024 with diagnosis including diabetes, cardiomegaly, and kidney disease. Resident 3's MARs from 02/01/25 through 02/28/25, corresponding Med Pass History from 02/01/25 through 03/02/25, and physician orders were reviewed and revealed the following medications lacked documented reasons for use: * Pregabalin 150 mg (anticonvulsant); * Aspirin 81 mg (analgesic); * Metoprolol 25 mg (blood pressure); * Mupirocin ointment (skin care); * Sertraline 100 mg (anti-depressant); * Pantoprazole 20 mg (proton pump inhibitor); * Desitin 40% paste (skin care); * Ferrous Sulfate (iron supplement); * Amiodarone 200 mg (cardiac Rythm); * Levofloxacin (anti-biotic); and * Furosemide 20 mg (diuretic). The need to ensure MARs for each resident the facility administered medications to included reason for use was reviewed on 03/05/25 with Witness 1 (RN Consultant) and on 03/06/25 with Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN). They acknowledged the findings. 4. Resident 4 moved into the facility in 11/2024 with diagnosis including chronic obstructive pulmonary disease (COPD), respiratory failure, spastic hemiplegia, and dysphagia. The resident's February MAR dated 02/01/25 to 02/28/25 and “Physician Order Sheet” dated 02/15/25 were reviewed and identified the following: Resident 4 was prescribed senna, polyethylene glycol powder, lactulose, sodium phosphate enema, and bisacodyl suppository for constipation. There were no parameters listed on the MAR for the PRN bowel medication that instructed staff what to administer first and in what order. The need to ensure MARs included resident-specific parameters for all PRN medications was reviewed with Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN) on 03/06/25 at 1:27 pm. They acknowledged the findings.

1. EMAR audit to be completed for residents 2, 3, and 4 by RN by alleged compliance date. Review for appropriate orders, indications, directions, interventions and administration steps for multiple orders with same indication to be evaluated. 2. Full EMAR audit reviewing appropriate orders, indications, directions, interventions and administration steps are accurate for all residents will be done by alleged compliance date. MT/RCC trained on proper pharmacy check-in and appropriate review of orders as a part of the three check process. Medications dashboard report review as part of daily clinical meeting. 3. Daily, weekly, monthly. 4. Administrator, RN, WD, RCC

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 (1a)(2-3) Acuity Based Staffing Tool - Elements (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING. Facilities must select and implement an acuity-based staffing tool (ABST) that is technology-based for determining appropriate staffing levels. Individual resident needs and care elements must be the primary consideration when developing and maintaining an ABST. Regardless of the ABST adopted, all requirements set forth in this rule and OAR 411-054-0034 (Resident Move in Evaluation) must be met. Facilities shall: (a) Select and implement the Department’s developed ABST or submit a proprietary ABST to the Department for approval as outlined in paragraph (2) of this rule. (2) PROPRIETARY ABST. A facility that chooses to use a proprietary ABST must implement a Department-approved ABST that meets this rule. (a) REQUIRED ELEMENTS. The proprietary ABST the facility adopts must meet the following requirements: (A) Address and document all individual ABST care elements outlined in paragraph (3) of this rule. (B) When calculating total time, the ABST must include the care elements for each resident and staff time needed to complete each individual care element. (C) Ensure the ABST can produce a report that identifies all residents currently residing in the facility, the care elements for each of the residents, and the staff time required to complete each care element for each resident. (D) Ensure the ABST can present the total time, in minutes, required to meet the scheduled needs for all residents, 24 hours a day, seven days a week, preferably per shift, per day. (E) Identify the date the resident’s ABST evaluation was last completed. (F) If applicable, determine ABST time for both residents on a Specific Needs Contract and residents not on a Specific Needs Contract to build posted staffing plans as outlined in this rule. (b) PROPRIETARY ABST REVIEW REQUEST. If a facility proposes to use a proprietary ABST, the facility must submit the ABST Proprietary Department Review Request (PDRR) Form, including but not limited to the following: (A) All facilities which currently have implemented a proprietary ABST must submit a PDRR Form no later than August 31, 2024. Facilities which do not submit a request on or before August 31, 2024, will be subject to corrective action as outlined in paragraph (9) of this rule. (B) Completed ABST PDRR Form. (C) Sample ABST report displaying all the ABST care elements listed in paragraph (3) of this rule, and the estimated staff time needed to complete each care element, shown per day, in minutes. Although not required, it is preferred that staff time be shown per shift, per day, in minutes. (D) The facility’s ABST policy required under OAR 411-054-0025(7)(i). (c) ABST SUMMARY STATEMENT. If the proprietary review request is approved, a facility must develop and maintain an ABST Summary Statement. The summary statement must be available upon request by the Department. An ABST summary statement must contain a general guide of how the ABST functions, as outlined on the PDRR form. (d) DEPARTMENT REVIEW OF PROPOSED PROPRIETARY ABST REQUEST. The Department will review and either approve or deny the facility’s proprietary ABST. The Department may request additional documentation, potentially including a virtual demonstration, to make the determination. If the ABST is deemed to not meet this rule, the Department may deny or rescind approval at any time. (e) APPEALS PROCESS. The Department will determine whether to approve or deny the request. If the proprietary ABST is denied or rescinded, the facility is entitled to a contested case hearing pursuant to ORS chapter 183. Prior to a contested case hearing, the facility may request an informal conference. (f) ANNUAL STATEMENT. Once approved, the facility must provide the Department an annual statement attesting no substantive changes have occurred to the design of the facility’s proprietary ABST that impacts its functionality. The facility must submit statements to the Department every year, between January 1 and March 31. (g) If the facility makes substantive changes to the design of its proprietary ABST that impacts the ABST’s functionality and if such changes would make the information submitted in support of its approval inaccurate or invalid, the facility must re-submit the ABST PDRR Form as described in this rule to the Department for review prior to implementing the new or revised ABST. (3) ABST CARE ELEMENTS. The required ABST care elements include activities of daily living and other tasks related to resident care and services, as outlined in OAR 411-054-0030, 411-054-0034, and 411-057- 0160. If any individual care element requires more than one staff, additional time must be accounted for as described in 411-054-0070(1). The ABST must individually address and document the care time required to complete each of the following individual ABST care elements: (a) Personal hygiene. (b) Grooming. (c) Dressing and undressing. (d) Toileting, bowel, and bladder management. (e) Bathing. (f) Transfers. (g) Repositioning. (h) Ambulation. (i) Supervising, cueing, or supporting while eating. (j) Medication administration. (k) Providing non-drug interventions for pain management. (l) Providing treatments. (m) Cueing or redirecting due to cognitive impairment or dementia. (n) Ensuring non-drug interventions for behaviors. (o) Assisting with leisure activities, assist with social and recreational activities. (p) Monitoring physical conditions or symptoms. (q) Monitoring behavioral conditions or symptoms. (r) Assisting with communication, assistive devices for hearing, vision, and speech. (s) Responding to call lights. (t) Safety checks, fall prevention (u) Completing resident specific housekeeping or laundry services performed by care staff. (v) Providing additional care services. If additional services are not provided, this element can be omitted. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation. Findings include, but are not limited to: The facility's ABST was reviewed and discussed by phone with Staff 26 (Vice President of Health Services) on 03/05/25 at 12:25 pm. The facility had implemented the Department’s ABST tool. The following was identified: * Seven former residents were entered into the ABST tool; * Five unsampled residents were not entered into the ABST tool; and * One sampled Specific Needs Contract resident (#4) had not been entered into the tool. The need to implement an ABST which met the regulation was discussed with Staff 26 (Vice President of Health Services) on 03/05/26 at 12:25 pm, and Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN) on 03/06/25 at 3:15 pm. They acknowledged the findings.

1. ABST fully updated on 3/12/25 removing any former residents and adding any current residents that were not entered yet. The remainder of the residents were reviewed and updated using caregiver reports on multiple shifts and while reviewing service plans in conjunction. Schedule and staffing have been updated to meet the needs in relation to ABST. RCC has the duty of maintaining the ABST with oversight of nurse and Administrator. 2. The ABST is updated promptly as changes occur ensuring reflecting current needs. The Administrator will assure that the RCC takes company training in relation to the ABST. New RCC and WD will be trained on the ABST. 3. Daily, weekly, monthly. 4. Administrator, WD, RCC

OAR 411-054-0037 (1a)(2-3) Acuity Based Staffing Tool - Elements (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING. Facilities must select and implement an acuity-based staffing tool (ABST) that is technology-based for determining appropriate staffing levels. Individual resident needs and care elements must be the primary consideration when developing and maintaining an ABST. Regardless of the ABST adopted, all requirements set forth in this rule and OAR 411-054-0034 (Resident Move in Evaluation) must be met. Facilities shall: (a) Select and implement the Department’s developed ABST or submit a proprietary ABST to the Department for approval as outlined in paragraph (2) of this rule. (2) PROPRIETARY ABST. A facility that chooses to use a proprietary ABST must implement a Department-approved ABST that meets this rule. (a) REQUIRED ELEMENTS. The proprietary ABST the facility adopts must meet the following requirements: (A) Address and document all individual ABST care elements outlined in paragraph (3) of this rule. (B) When calculating total time, the ABST must include the care elements for each resident and staff time needed to complete each individual care element. (C) Ensure the ABST can produce a report that identifies all residents currently residing in the facility, the care elements for each of the residents, and the staff time required to complete each care element for each resident. (D) Ensure the ABST can present the total time, in minutes, required to meet the scheduled needs for all residents, 24 hours a day, seven days a week, preferably per shift, per day. (E) Identify the date the resident’s ABST evaluation was last completed. (F) If applicable, determine ABST time for both residents on a Specific Needs Contract and residents not on a Specific Needs Contract to build posted staffing plans as outlined in this rule. (b) PROPRIETARY ABST REVIEW REQUEST. If a facility proposes to use a proprietary ABST, the facility must submit the ABST Proprietary Department Review Request (PDRR) Form, including but not limited to the following: (A) All facilities which currently have implemented a proprietary ABST must submit a PDRR Form no later than August 31, 2024. Facilities which do not submit a request on or before August 31, 2024, will be subject to corrective action as outlined in paragraph (9) of this rule. (B) Completed ABST PDRR Form. (C) Sample ABST report displaying all the ABST care elements listed in paragraph (3) of this rule, and the estimated staff time needed to complete each care element, shown per day, in minutes. Although not required, it is preferred that staff time be shown per shift, per day, in minutes. (D) The facility’s ABST policy required under OAR 411-054-0025(7)(i). (c) ABST SUMMARY STATEMENT. If the proprietary review request is approved, a facility must develop and maintain an ABST Summary Statement. The summary statement must be available upon request by the Department. An ABST summary statement must contain a general guide of how the ABST functions, as outlined on the PDRR form. (d) DEPARTMENT REVIEW OF PROPOSED PROPRIETARY ABST REQUEST. The Department will review and either approve or deny the facility’s proprietary ABST. The Department may request additional documentation, potentially including a virtual demonstration, to make the determination. If the ABST is deemed to not meet this rule, the Department may deny or rescind approval at any time. (e) APPEALS PROCESS. The Department will determine whether to approve or deny the request. If the proprietary ABST is denied or rescinded, the facility is entitled to a contested case hearing pursuant to ORS chapter 183. Prior to a contested case hearing, the facility may request an informal conference. (f) ANNUAL STATEMENT. Once approved, the facility must provide the Department an annual statement attesting no substantive changes have occurred to the design of the facility’s proprietary ABST that impacts its functionality. The facility must submit statements to the Department every year, between January 1 and March 31. (g) If the facility makes substantive changes to the design of its proprietary ABST that impacts the ABST’s functionality and if such changes would make the information submitted in support of its approval inaccurate or invalid, the facility must re-submit the ABST PDRR Form as described in this rule to the Department for review prior to implementing the new or revised ABST. (3) ABST CARE ELEMENTS. The required ABST care elements include activities of daily living and other tasks related to resident care and services, as outlined in OAR 411-054-0030, 411-054-0034, and 411-057- 0160. If any individual care element requires more than one staff, additional time must be accounted for as described in 411-054-0070(1). The ABST must individually address and document the care time required to complete each of the following individual ABST care elements: (a) Personal hygiene. (b) Grooming. (c) Dressing and undressing. (d) Toileting, bowel, and bladder management. (e) Bathing. (f) Transfers. (g) Repositioning. (h) Ambulation. (i) Supervising, cueing, or supporting while eating. (j) Medication administration. (k) Providing non-drug interventions for pain management. (l) Providing treatments. (m) Cueing or redirecting due to cognitive impairment or dementia. (n) Ensuring non-drug interventions for behaviors. (o) Assisting with leisure activities, assist with social and recreational activities. (p) Monitoring physical conditions or symptoms. (q) Monitoring behavioral conditions or symptoms. (r) Assisting with communication, assistive devices for hearing, vision, and speech. (s) Responding to call lights. (t) Safety checks, fall prevention (u) Completing resident specific housekeeping or laundry services performed by care staff. (v) Providing additional care services. If additional services are not provided, this element can be omitted. This Rule is not met as evidenced by:

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to complete an acuity-based staffing tool (ABST) that accurately captured care time and care elements that staff provided to each resident as outlined in each individual service plan for 2 of 4 sampled residents (#s 3 and 4) whose ABST was reviewed. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 11/2024 with diagnosis including chronic obstructive pulmonary disease (COPD), respiratory failure, spastic hemiplegia, and dysphagia. On 03/05/25, the facilities ABST was reviewed and identified Resident 4 had not been entered into the ABST. Therefore, there was no documented evidence the facility accurately captured care time and/or care elements that staff provided to the resident. The need to accurately capture care time and care elements on the resident's ABST was discussed with Staff 1 (ED), Staff 3, and Staff 25 (RN) on 03/06/25 at 1:27 pm. They acknowledged the findings. Resident 3 was admitted in 09/2024 with diagnosis including diabetes, cardiomegaly, and kidney disease. 2. On 03/05/25, the facilities ABST was reviewed and identified Resident 3’s ABST had not been updated since 11/2024 and was not updated with a significant change in condition on 02/28/25. Resident 3’s service plan showed staff assistance was required in the following areas, but was not accounted for on the ABST: * Transferring in or out of bed or chair; * Dressing and undressing; and * Grooming such as nail care and brushing hair. The need to accurately capture care time and care elements on the resident's ABST was discussed with Staff 1 (ED), Staff 3, and Staff 25 (RN) on 03/06/25 at 1:27 pm. They acknowledged the findings.

1. Resident 3 was updated on the ABST specifc to the items mentioned in the SOD. Resident 4 is under our specific needs contract and does not get entered into ABST. The remainder of the residents were reviewed and updated using caregiver reports on multiple shifts while reviewing service plans in conjunction. Schedule and staffing have been updated to meet the needs in relation to ABST. 2. The new RCC will be trained on the ABST and will update daily as needed with move ins, move outs, or changes in care needs. 3. Daily, weekly, monthly. 4. Administrator, WD, RCC

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

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) was updated no less than quarterly for 2 of 4 (#2 and 4) sampled resident’s, multiple unsampled residents and/or with a significant change of condition for 2 of 3 residents with significant change of condition (#3 and 4). Findings include, but are not limited to: During the acuity interview at 9:52 am on 03/03/25, Staff 5 (RCC) confirmed the facility census was at 47 residents. The facility’s ABST data and posted staffing plan were reviewed at 9:50 am on 03/05/25 and revealed the following: a. One sampled resident (#4) and five unsampled residents had no ABST data. b. Seven residents who no longer resided at the facility were listed in the ABST data. c. Resident 2 had no documented evidence the ABST data had been updated quarterly. d. Resident 3 experienced a significant change of condition on 03/01/25 and there was no documented evidence the ABST data had been updated. e. Resident 4 experienced a significant change of condition on 02/26/25 and there was no documented evidence the ABST data had been updated. During an interview by phone on 03/05/25 at 12:25 pm, Staff 26 (Vice President of Health Services) stated the facility staff had been trained on the ABST and she “turned it over” to the facility and they were responsible for updating the ABST data at the same time the service plan was being updated and/or with significant change of condition. Staff 26 acknowledged the ABST findings. No additional documentation was provided. The need to ensure residents’ ABST was updated no less than quarterly and/or with significant change of condition was discussed with Staff 26 on 03/05/25 at 12:25 pm and Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN) on 03/06/25 at 3:15 pm. They acknowledged the findings.

1. Refer to C362. All residents were updated on the ABST as well as specifc to the items mentioned in the SOD. The remainder of the residents were reviewed and updated using caregiver reports on multiple shifts and while reviewing service plans in conjunction. Schedule and staffing have been updated to meet the needs in relation to ABST. 2. The new RCC will be trained on the ABST and will update daily as needed with move ins, move outs, or changes in care needs. 3. Daily, weekly, monthly. 4. Administrator, WD, RCC

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 2 of 3 newly hired caregivers (#s 8 and 13) completed all required pre-service orientation training. Findings include, but are not limited to: Staff training records were reviewed on 03/04/25 at 1:00 pm with Staff 4 (Business Office Manager) and the following was identified: There was no documented evidence Staff 8 (CG hired on 11/07/24) and Staff 13 (CG hired on 12/1/24) completed the following required pre-service orientation topics prior to beginning their job responsibilities: * Resident rights and values of CBC care; * Abuse reporting requirements; * Fire safety and emergency procedures; * Written job description; and * Pre-service dementia training. There was no documented evidence Staff 13 (CG hired on 12/1/24) completed the required pre-service infectious disease prevention. The requirements for documented pre-service orientation and training for all employees were reviewed with Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN) on 03/6/25 at 3 pm. They acknowledged the findings.

1. Staff #8 has completed the missing pre-service orientation topics Staff #13 no longer employed. Completed a training audit to assure that all staff are trained per policy and OAR. All staff trainings to be completed by the alleged compliance date. 2. A training tracker spreadsheet has been implemented to ensure training is completed and recorded timely per OARs. Relias and Oregon Care Partners approved classes are utilized for compliance followed by company approved orientation and competencies done for each employee. 3.Daily, weekly, monthly. 4. Administrator, BOM

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 3 of 3 newly hired direct care staff (#s 9, 11, and 17) demonstrated satisfactory performance in all assigned duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 03/04/25 at 1:00 pm with Staff 4 (Business Office Manager) and the following was identified: There was no documented evidence staff demonstrated satisfactory performance within 30 days of hire of the following required elements: * Staff 17 (MT) hired on 1/28/25 and Staff 11 (CG) hired on 1/20/25 were missing documentation of the required “Changes associated with normal aging”; and * Staff 9 (CG hired on 1/3/25) and Staff 11 (CG hired on 1/20/25) did not have documentation of having demonstrated competency in First aid and Abdominal thrust. The requirements for documented pre-service orientation and training for employees were reviewed with Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN) on 3/6/25 at 3 pm. They acknowledged the findings.

1. Employee # 9, 11, and 17 are in process of completing all required trainings associated with the 30-day training. A complete training audit under review to assure that all staff are trained per policy and OAR. All staff to be completed by the alleged compliance date. 2.Refer to C370. Designated staff trainers perform competency checks on their department staff to observe demonstrated performance skills. 3. Daily, weekly, monthly. 4. Administrator, BOM

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 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff (6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF. (a) Annual infectious disease training requires the following: (A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training. (B) Annual in-service training must be documented in the employee record. (b) Biennial LGBTQIA2S+ training requires the following: (A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff. (i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite. (ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. (vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state. (D) The proposal for training submitted by a facility, entity, or individual shall include: (i) The regulatory criteria described in paragraph (C) of this section as part of the proposal. (ii) The following elements must be included in the proposal: (I) A statement of the qualifications and training experience of the facility, individual or entity providing the training; (II) The proposed methodology for providing the training either online or in person. (III) An outline of the training. (IV) Copies of the materials to be used in the training. (iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision. (c) Annual Home and Community-Based Services (HCBS) training requires the following: (A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations. (B) Annual in-service training must be documented in the employee record. (C) These annual trainings will be required as of April 1, 2025. (7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF. (a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire. (b) Requirements for annual in-service dementia training: (A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care. (B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter. (C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above. (D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia. (E) The facility shall determine the competency of direct care staff in dementia care in the following ways: (i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19). (ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff. (iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency. (8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 1 of 1 long-term staff (#14) completed 12 hours of annual in-service training, including at least six hours of dementia care, and failed to complete Home and Community Based Services training and LGBTQIA2+ inclusion training as required. Findings include, but are not limited to: Staff training records were reviewed on 03/04/25 at 1:00 pm with Staff 4 (Business Office Manager) and the following was identified: a. There was no documented evidence Staff 14 (CG hired on 05/21/22) completed at least 12 hours of training based on their anniversary date of hire related to the provision of care in CBC, including a minimum of six hours of training on dementia care topics. The need to ensure and document that long-term direct care staff completed the required number of hours of annual in-service training and annual infectious disease training was discussed with Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN) on 3/6/25 at 3 pm. They acknowledged the findings.

1. Staff member #14 has completed over 33hrs of annual in-service training related to the provision of care in CBC 10 of which are related to dementia care. HCBS and LGBTQIA2+ training to be completed by alleged compliance date. 2. Refer to C370. Annual training plan in place for all direct care staff. 3. Daily, weekly, monthly. 4. Administrator, BOM

OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff (6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF. (a) Annual infectious disease training requires the following: (A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training. (B) Annual in-service training must be documented in the employee record. (b) Biennial LGBTQIA2S+ training requires the following: (A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff. (i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite. (ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. (vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state. (D) The proposal for training submitted by a facility, entity, or individual shall include: (i) The regulatory criteria described in paragraph (C) of this section as part of the proposal. (ii) The following elements must be included in the proposal: (I) A statement of the qualifications and training experience of the facility, individual or entity providing the training; (II) The proposed methodology for providing the training either online or in person. (III) An outline of the training. (IV) Copies of the materials to be used in the training. (iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision. (c) Annual Home and Community-Based Services (HCBS) training requires the following: (A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations. (B) Annual in-service training must be documented in the employee record. (C) These annual trainings will be required as of April 1, 2025. (7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF. (a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire. (b) Requirements for annual in-service dementia training: (A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care. (B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter. (C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above. (D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia. (E) The facility shall determine the competency of direct care staff in dementia care in the following ways: (i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19). (ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff. (iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency. (8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process. 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 and documented every other month and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to: Fire and life safety records, reviewed between 09/2024 and 03/2025, revealed the following: a. The facility lacked documented evidence fire drills were conducted and documented every other month, with all required components. b. The facility lacked documented evidence fire and life safety training instruction was provided to staff on alternating months from fire drills. On 03/04/25 at 12:01 pm, Staff 2 (Facility Service Director) confirmed the lack of documented evidence of fire drills and fire and life safety training for staff. The need to ensure fire drills and fire and life safety training was provided and documented as required was reviewed with Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN) on 03/06/25 at 1:27 pm. They acknowledged the findings.

1. Effective immediately, the Maintenance Director will be conducting and documenting fire drills every other month with all required components. The Maintenace Director will also be responsible for fire and life safety training instruction alternating months from fire drills at the monthly all staff meeting. Orientation checklist has fire safety and fire locations performed by the Maintenance Director for all new staff. 2. Fire Drills and Fire and Life Safety training will alternate monthly and be completed by the end of each month and documentation will be kept together in a binder located in the BOM office. 3. Monthly 4. Administrator, Maintenance Director

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by:

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory care communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were maintained in good repair. Findings include, but are not limited to: On 03/04/25 at 12:34 pm, during a walk-through of the facility with Staff 2 (Facility Service Director) and Staff 24 (Facility Service Aide) the following was identified: a. The pathway along the front of the facility had multiple areas with broken material that created uneven gaps on the pathway, measured up to one and a half inches wide. This created potential fall hazards to the residents. b. There were multiple drop-offs measured up to four inches from the concrete to the ground, identified around the exterior perimeter pathways of the facility and in the interior courtyard along the concrete patio and courtyard doors. This created potential fall hazards to the residents. The need to ensure all exterior pathways were maintained in good repair was reviewed with Staff 1 (ED) and Staff 3 (Wellness Director) on 03/06/25 at 1:27 pm. They acknowledged the findings.

1. Maintenance Director in process of repairing the broken material, uneven gaps and drop-offs on pathways along the front of the community, interior courtyard along the concrete patio, courtyard doors, and other exterior pathways by adding additional dirt, gravel and multi-bark to the mentioned areas to ensure all unsafe areas are eliminated. 2. Repair log implemented. Maintenance Director keeps track of needed upkeep, cleaning, repairs and completions. 3. Daily, weekly, monthly. 4. Administrator, Maintenance Director

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory care communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by:

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: On 03/04/25 and 03/06/25, during a walk-through of the facility with Staff 2 (Facility Service Director) and Staff 24 (Facility Service Aide) the following was identified: a. The exterior of the facility had multiple tarps covering areas identified by the facility which required repair on the roof. The tarps were located in the interior courtyard and along the back side of the facility. b. Interior areas of the facility, found not clean and/or in good repair: * Multiple doors and door frames including the public restroom doors, exit doors, private dining room door, resident laundry room door, and room numbers 101, 104, 105, 107, 108, 110, 111, 118, 119, 124, 126, 129, 134, 135, 136, 137, 138, 142, 146, 151, and 153; * Two resident room windows had heavy condensation located on the left side of the interior courtyard; * Front desk area had gouged and missing material; * Hole in the ceiling located near room 131; * The packaged terminal air conditioner unit located near room 118 had a cover that was falling off and not secure; * Broken dryer handle in the resident laundry room; * Activity room door had a metal divider that was bent and damaged; and * Wooden furniture in the lobby and dining room, including a desk, coffee table, and chest. On 03/06/25 at 10:20 am, Staff 2 and Staff 24 confirmed they were aware of areas identified. The need to ensure all materials and surfaces were kept clean and in good repair was reviewed with Staff 1 (ED) and Staff 3 (Wellness Director) on 03/06/25 at 1:27 pm. They acknowledged the findings.

1. Roof has been patched and repaired, all areas are water tight, and tarps have been removed. The Maintenance Director has begun working on all survey identified interior areas in need of cleaning, repair and new paint. Doors and frames are in process of being evaluated and repaired/painted. 2. Repair log implemented. Maintenenace Director keeps track of needed upkeep, cleaning, repairs and completions. 3. Daily, weekly, monthly. 4. Administrator, Maintenance Director

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by: