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 reflective of residents' needs, provided clear direction regarding the delivery of services, were implemented, and were reviewed and updated following a significant change of condition for 2 of 6 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 11/2023 with diagnoses including type 2 diabetes and pancreatitis. Resident 1's 03/11/25 service plan and progress notes dated 01/10/25 through 03/27/25 were reviewed, the resident was observed, and staff were interviewed. The service plan had not been updated when the resident experienced a significant change of condition on 3/20/25, related to increased falls and subsequent hospitalizations. Additionally, the service plan was not reflective and did not provide clear caregiving instruction in the following areas: * Nonadherence to treatment plans; * Signs and symptoms of low and high blood sugar; * Decreased food intake, including nutritional interventions; * Episodes of severe pain, nausea and vomiting; and * PRN pain medication, including non-pharmaceutical interventions. On 04/03/25, the need to ensure service plans were updated after a significant change of condition was identified, were reflective of current care needs, and provided clear instruction to staff was discussed with Staff 1 (ED), Staff 2 (LPN), Staff 5 (RCC) and Staff 6 (RCC). They acknowledged the findings. 2. Resident 2 was admitted to the facility in 05/2023 with diagnoses including chronic back pain. Observations of the resident, interviews with staff and review of the service plan, dated 01/28/25, showed the service plan was not reflective of the resident's current care needs, was not consistently implemented and/or did not provide clear direction to staff in the following areas: * Air mattress, floating heels/elbows and low bed; * Private caregiver and feeding assistance; * Overbed table kept close to the resident, ensuring fluids within reach; * ADL assistance of 1 staff vs 2 staff; * Use of an incontinence wrap; * Bed bath, outside of hospice services; * Dentures and hearing aide; * Side rail use; and * Hallucinations. The need to ensure resident service plans were reflective of current care needs, were consistently implemented and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (LPN), Staff 5 (RCC) and Staff 6 (RCC) on 04/02/25. They acknowledged the findings.

The ED/Designee with audit all evaluation/service plans to ensure that all required items are captured with input from care staff, programming staff, resident and families. Resident 1 and Resident 2's service plan will be updated by the Health Services Director (HSD) by __4/18/2025. A weekly audit of evaluation/service plan dates will be done by the ED/Designee once weekly x 4 weeks , then bi-weekly x 4 weeks and then monthly so that evaluations/service plans are completed prior to move in, within 30 days, quarterly and with changes of condition and they are readily available to staff. Weekly Audit with Department Head Team to ensure Service plans are accurately reflecting current needs and preferences, review two residents weekly.

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 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure short term changes in condition had documented progress monitored at least weekly through resolution for 2 of 6 sampled residents (#s 2 and 4) who experienced short term changes of condition. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 05/2023 with diagnoses including chronic back pain. The resident's 01/28/25 service plan, 12/03/24 through 03/31/25 observation notes, incident investigations and physician communications were reviewed. The resident experienced multiple short-term changes without noted progress at least weekly until resolved, and/or lacked resident-specific directions to staff in the following areas: * Medication changes; * Skin injuries/breakdown to multiple areas; * Dark urine and urinary tract infection (UTI); * Vomiting; * Medication error; and * Hallucinations. The need to ensure short-term changes of condition had documentation of weekly progress until resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED), Staff 2 (LPN), Staff 5 (RCC) and Staff 6 (RCC) on 04/02/25. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 06/2021 with diagnoses including dementia. The resident's 02/11/25 service plan,12/02/24 through 03/31/25 observation notes, incident investigations and physician communications were reviewed. The resident experienced multiple short-term changes without noted progress at least weekly until resolved, and/or lacked resident-specific directions to staff in the following areas: * Medication changes; * Falls with and without injuries and ER visits; * Bruising, rashes and/or skin breakdown to multiple areas of the body; * Increased confusion; and * Illness and UTI. The need to ensure short-term changes of condition had documentation of weekly progress until resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED), Staff 2 (LPN), Staff 5 (RCC) and Staff 6 (RCC) on 04/02/25. They acknowledged the findings.

The Regional Director of Health Services(RDHS) will provide in-service for the ED and HSD on OAR 411-054-0040(1&2): Change of Condition and Monitoring. The ED/Designee will peform an audit of current at-risk residents to identify any change of condition needs and RN Delegate will be consulted if appropriate. The ED/ HSD or Designee will monitor the Electronic Health Record at least 4 days/week for incidents and progress notes to identify any resident changes and communicate to RN Delegate any change of condition needs.This review will be completed daily in Clinical Huddle The HSD or Designee will clearly document initation, weekly monitoring and resolution of each change of condition in the EHR The RDHS to audit weekly X4 weeks, bi-weeklyx4 weeks, and then spot check monthly.

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

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure a timely RN assessment was completed which included documented findings, resident status, and interventions made as a result of the assessment for 2 of 5 sampled residents (#s 2 and 4) who experienced significant changes of condition. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 05/2023 with diagnoses including chronic back pain. Observations of the resident, interviews with staff, review of the service plan, dated 09/30/24 and 12/02/24 through 03/31/25 observation notes, physician communications and hospice visit notes were completed. The resident required full assistance from staff for all ADL care. The resident required two staff for positioning, transfers, bed changes and incontinent care. The resident’s intake was poor to fair. S/he was inconsistently able to feed himself/herself and needed assistance for meal intake. A private caregiver had been hired to assist the resident with the lunch and dinner meals each day; the caregiver provided full feeding assistance to the resident. Multiple observations of the resident between 03/31/25 and 04/02/25 showed the resident in bed. The resident was bedbound and spent most of his/her time sleeping. His/her intake was between 0% and 25% for all meals observed. The resident was fed by the private caregiver, the resident ate very minimal bites of food on his/her own. The resident was discharged from hospice on 12/27/24. The resident was again admitted to hospice on 03/01/25 after further decline in condition and significant decrease in meal intake. The resident spent most of the time sleeping and/or groggy, fully bedbound and had little to no appetite. The resident had frequent pain with movement of his/her lower extremities, turning and positioning. In an interview on 04/02/25, Staff 3 (RN) indicated she started with the facility as a consultant on 03/05/25. She was not made aware of the resident’s readmission to hospice until 03/20/25. When she became aware of the changes and hospice admission, she completed an assessment. Staff 3 acknowledged that the interventions she noted were not resident specific and should be more personalized to the individual resident needs. The facility failed to ensure a timely RN assessment was completed for the resident’s decline in condition and lack of intake, which included resident status and interventions made as a result of the assessment. The need to ensure an RN assessment was completed which documented findings, resident status, and resident specific interventions made as a result of the assessment was discussed with Staff 1 (ED), Staff 2 (LPN), Staff 5 (RCC) and Staff 6 (RCC) on 04/02/25. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 06/2021 with diagnoses including dementia. The resident's 02/11/25 service plan,12/02/24 through 03/31/25 observation notes, incident investigations, hospital visit notes and physician communications were reviewed. The resident required one person assistance with ADLs. The resident used a walker around his/her apartment and was assisted with a wheelchair for longer distances. The resident could eat and drink on his/her own and typically attended meals in the dining room. The resident had short term memory issues and could be forgetful. S/he was able to make some needs known. Multiple daily observations between 03/31/25 and 04/02/25 showed the resident in common areas as well as in his/her apartment. The resident frequently was seated in the recliner in his/her room and watching television or napping. The resident attended all three meals each day in the dining room and multiple activities that occurred in the facility. The resident used the walker to move between the dining room and activity room with staff assistance. The resident ate more than 75% of meals and fluids provided. a. Weight records, dated 11/06/24 through 03/31/25, indicated the resident experienced the following: * The resident’s weight on 11/06/24 was 223.5 pounds. The resident’s next recorded weight was 211.8 pounds on 12/11/24. The resident experienced a severe weight loss of 11.7 pounds or 5.23% in a month. * The resident gained 3.8 pounds between 12/11/24 and 01/02/25 which was not a significant gain. The resident’s weight continued to trend upwards from 215.8 pounds on 01/02/25 to 224 pounds on 02/04/25. This was an 8.4 pound increase or 3.89% gain in one month. The resident’s weight currently remained around 220 pounds in March 2025 with no additional significant gains or losses. In an interview on 04/02/25, Staff 2 (LPN) indicated she was unable to locate any RN assessment of the resident’s December 2024 weight loss. The resident’s intake was usually good. The resident was being treated for a UTI in mid to late December 2024 which may have affected the resident’s intake at the time. The resident did have some recurring edema to the lower extremities as well. The facility failed to ensure a timely RN assessment was completed for the significant weight loss, which included resident status and interventions made as a result of the assessment. b. Observation notes showed the resident experienced multiple falls between 01/01/25 and 02/01/25. The resident was evaluated at the ER for several of the falls because of pain complaints or concerns the resident had hit his/her head. The After Visit Summary dated on 01/13/25 indicated the resident was seen for a fall which resulted in multiple rib fractures. The resident returned to the facility with an order for lidocaine for pain. The instructions included limits to movement based on pain concerns, rest and ice. In interviews between 03/31/25 and 04/02/25 the following was noted: Staff 13 (MT) and Staff 21 (CG) indicated the resident had some pain when the fracture occurred and did require some additional assistance from staff. The resident was not independent prior to the fracture, needed one person assistance for toileting and had more difficulty with certain positions or movements. The staff indicated the resident continued to require one staff for assistance, was able to make some needs known and pain seemed to be back to baseline. The resident’s cognition was about the same as previous with some forgetfulness and a bit of confusion. Staff 2 (LPN) indicated at the time the resident experienced a fall and sustained the rib fractures s/he did not seem to be in a great deal of pain or limited in movement. The care staff were aware of the need to assist the resident with care due to the fractures. Staff 2 was unable to locate any RN assessment of the resident’s rib fracture. Staff 3 (RN) indicated she was not with the facility at the time of the fracture, so she did not complete any significant change. The resident did not have any current issues that required a significant change of condition. The resident indicated s/he received medications when needed, plenty of food and fluids and was not experiencing any current pain issues. The resident could not specifically remember the fall that led to the fractures or any issues around the injury during that time period. The resident indicated currently s/he was doing well. The facility failed to ensure an RN assessment was completed timely for the resident’s rib fractures, which included resident status and interventions made as a result of the assessment. The need to ensure an RN assessment was completed which documented findings, resident status, and resident specific interventions made as a result of the assessment was discussed with Staff 1 (ED), Staff 2 (LPN), Staff 5 (RCC) and Staff 6 (RCC) on 04/02/25. They acknowledged the findings.

The Regional Director of Health Services(RDHS) will provide in-service for the ED and HSD on OAR 411-054-0040(1&2): Change of Condition and Monitoring. The ED/Designee will peform an audit of current at-risk residents to identify any change of condition needs and RN Delegate will be consulted if appropriate. THe ED/HSD or Designee are responsible to notify the RN delegate of significant change of condition when it is identified. RN Delegate will perform Significant COC assessment within 48 hours. The HSD or Designee will review resident's weights monthly and notify the RN delegate of significant weight changes: 5% or more in one month; 7.5% or more in three months or 10% weight change in six months. RN Delegate in coordination with the HSD will initiate TSP with resident centered interventions towards change of conditions, monitor the effectiveness of the interventions at least weekly until there is resolution or resident has established a new baseline. The HSD will attend and complete the Role of the Nurse in CBC course througth OHCA May 6- May 8, 2025

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 411-054-0090 (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 provide documentation that fire drills included all required components and failed to provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to: Fire and life safety records for the prior six month were reviewed with Staff 4 (Maintenance Director) on 04/02/25. a. Fire drills conducted lacked the following required components: * Escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; and * Number of occupants evacuated. b. There was no documentation fire and life safety instruction for staff was being conducted on alternative months from fire drills. The need to include required components in fire drills and provide fire and life safety instruction to staff on alternate months from fire drills, was discussed with Staff 4 on 04/02/25 and Staff 1 (ED) on 04/03/25. They acknowledged the findings.

Maintenance Director (MTD) will be educated by Director of Facilities on expectations of fire drills and requirement of alternating monthly fire and life safety trainings. The updated fire drill report was placed in use 4/15/2025 and contains all required information: escape route used, problems encountered and comments relating to residents who resisted/failed to participate; evacuation time needed and number of occupents evacuated. Fire Drills and Monthly all staff meeting education will be tracked utilizing the appropriate forms and uploaded into TELS. Fire Drills will be reported throught he monthly CQI meeting. Business Office Manager (BOM) or Designee will track all staff training as completed and report to ED. ED/Designee will audit the fire drill forms monthly to ensure all required information is contained. Results will be reported to the Continuous Quality Improvement Committee.

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

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to provide documentation of instruction to residents within 24 hours of admission in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire and failed to reinstruct residents at least annually. Findings include, but are not limited to: On 04/02/25, Staff 4 (Maintenance Director) reported that he provided residents with information regarding fire drills when they moved in, but that there was no documentation of this instruction. In an interview on 04/03/25 Staff 1 (ED) reported there was currently not a system in place for reinstructing residents annually in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places in the event of an actual fire. The need to ensure the required fire and life safety instruction was provided to residents within 24 hours of admission and at least annually thereafter, was discussed with Staff 4 on 04/02/25 and with Staff 1 on 04/03/25. They acknowledged the findings.

Executive Director and Maintenance Director were educated by the Regional Director of Operations about resident education of fire safety/evacuation protocol within 24 hours of move in and annually. 2. Maintenance Director or designee will meet with every move in within 24 hour time period to discuss what to do in the event of a fire emergency. 3. Resident fire and life safety education will be provided by the Maintenance Director/ED/Designee by 5/31/2025. The MTD or designee will schedule annual resident fire and life safety training in TELS. ED/designee will report compliance each month to the Continuous Quality Improvement Committee.

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

OAR 411-054-0300 (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 interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: The facility was toured on 04/01/25 and 04/02/25. The following were identified: * The majority of dining room chairs and tables had areas of bare, splintered wood; * Several dining room tables had dried food on the pedestal bases; and * Resident rooms 138 and 218 had darks spots and stains on the carpet. The above areas needing cleaning and repair were reviewed with Staff 1 (ED) and Staff 4 (Maintenance Director) on 04/02/25. They acknowledged the findings.

1. Rooms 138 and 218 had spots on carpets cleaned by the maintenance director; Dried food on the pedestal bases of the tables has been cleaned.Tables and Chairs have begun sanding and re-staining process. 2. All staff were trained by the Maintenance Director/ED on how to use the carpet cleaner to be able to clean carpets in a timely manner. Tables and chairs now on a cleaning schedule in order to ensure both cleanliness and ability to maintan every day wear and tear. 4. Maintenance Director and Executive Director will do a monthly walkthrough to audit cleanliness. This will be reported to the Continuous Quality Improvement Committee.

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: