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 residents were treated with dignity and respect when receiving meal delivery to their apartments. Findings include, but are not limited to: During an observation, on 04/07/25 at 12:05 pm, meals delivered to resident rooms were served in disposable containers, drinks were in disposable cups and utensils were plastic. The meals served to residents in the dining room were served on ceramic dishes with stainless steel flatware. During an interview on 04/08/25 at 10:10 am, Staff 4 (Dietary Services Manager) stated all meals delivered to residents in their room, were served on disposable products on a daily basis. Ensuring residents were treated with respect and dignity with regards to meal service was discussed on 04/08/25 at 10:10 am with Staff 4 and on 04/08/25 at 10:15 am with Staff 1 (ED). They acknowledged room trays were served with disposable service items and indicated the facility would proceed with purchasing more service items for room trays.

1. Community has ordered more drinkware, dishware, utensils and plate covers to accommodate apartment meal trays without the need for disposable containers. 2. Dietary Manager and all Dining Services teams have been inserviced on not using disposable containers, drinkware and flatware for apartment meals trays. 3. Dietary manager and Executive Director will spot check meal services weekly to ensure no disposable supplies are used in meal trays. 4. Executive 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 411-054-0036 (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' current care needs and provided clear instructions to staff for 3 of 4 sampled residents (#s 2, 4, and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 12/2022 with diagnoses including diabetes. Resident 2's service plan was reviewed, and caregiving staff and the resident were interviewed. The service plan which was available to direct care staff was dated 10/21/24, and not quarterly. Additionally, the service plan was not reflective of the resident's current status and/or lacked clear instructions to staff in the following areas: *Dressing; *Bowel care; and On 04/10/25 at approximately 11:30am, the need to ensure service plans were reflective of the resident's current status, provided clear instruction to staff, and the most recent service plan was available to staff was discussed with Staff 1 (ED), Staff 2 (LPN), and Staff 3 (RN). They acknowledged the findings. 2. Resident 4 was admitted to the facility in 11/2023 with diagnoses including insulin dependent diabetes mellitus type 2 and dysphagia. Observations were made of the resident's care on 04/08/25 and 04/09/25, interviews with the resident and facility staff were conducted, and the service plan dated 02/20/25 was reviewed. Resident 4's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Current diet texture and liquid consistency; * Instructions for proper maintenance of blood sugar monitor on right upper extremity and how to monitor for malfunctions; * Instructions on whom to report signs and symptoms of hypo- and hyperglycemia; * Instructions to staff on blood glucose monitoring protocol when resident sleeps late and skips meals; * Instructions on signs and symptoms of depression to report while on anti-depressant therapy; * Instructions on whom to report skin impairments; * Incorrect reference to resident self-administering medications; * Ambulation and use of assistive devices; * Electric wheelchair equipment precautions and instructions for proper maintenance; * Oxygen equipment precautions, instructions for proper maintenance, and how to monitor for safety; * How side rails were to be used and monitored for safety; and * Instructions for aspiration precautions and interventions while choking. The need to ensure service plans reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (ED), Staff 2 (LPN/Director of Health Services), and Staff 3 (RN) on 04/10/25 at 11:35 am. They acknowledged the findings. 3. Resident 5 was admitted to the facility in 07/2022 with diagnoses including Type 2 diabetes, rheumatoid arthritis, and spinal stenosis. Observations of the resident, interviews with staff and resident and review of the resident’s most recent service plan, dated 03/21/25 was completed. The following areas were not reflective of residents’ current care needs and/or failed to provide clear directions to staff regarding the delivery of services: * Mental health; * Personality and behaviors; * Dressing; * Laundry related to frequency; and * Transferring. 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) and Staff 2 (LPN/Director of Health Services) on 04/10/25 at 11:00 am. The findings were acknowledged.

C260 - Service Plan General 1. Service plans for resident #2, 4 and 5 were reviewed and updated to reflect resident's current care needs and have clear directions to staff regarding the delivery of services. 2. To prevent recurrance, all current resident service plans will be audited for accuracy. Direct care staff were reeducated regarding the importance of implementing current service plans and reporting any discrepancies. Training with Health Services team completed to ensure service plans are updated for accuracy and they provide clear direction to care team. Monitored during Stand up/Clinical meeting to review upcoming evals/service plan reviews that need to be completed as well as to note when there are changes of condition that could require an update more frequent than quarterly schedule. 3. Service plan schedule and residents with change of conditon and significant change of condition are reviewed during Stand-up and clinical meetings. Service plans will be evaluated and reviewed upon admission, at 30 days, quarterly and with significant change of condition. 4. Executive Director and Health Services

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 411-054-0090 (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 conduct unannounced fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to: On 04/07/25, fire drill and fire and life safety records for the previous six months were requested. Review of the documentation provided revealed: * Fire drills were not conducted every other month; * Fire drill records did not include location of simulated fire origin; and * Staff was not evacuating or relocating residents during fire drills; therefore, the facility's fire drill documentation did not include information on escape route used, problems encountered and comments relating to residents who resisted or failed to participate in the drills, and number of occupants evacuated. The requirements regarding fire drills were discussed with Staff 1 (ED) and Staff 5 (Maintenance Director) on 04/07/25 at 1:37 pm. They acknowledged the findings.

C420 - Fire and Life Safety 1. Maintenance Director reeducated on the requirement to accurately document Fire Drills on alternating months to include relocation of residents. The community had a full fire drill to include relocation of residents and full completion of fire drill form including location of simulated fire origin, escape routes used and comments related to residents who failed to participate in the drills and number of residents who were evacuated. 2. Computer program used for scheduling maintenance tasks has been reviewed to ensure it is populating the drills on alternating months and to ensure staff have received Fire and Life Safety training. Drills will be conducted and documented every other month. 3. Fire drills and Inservice schedule will be reviewed monthly at CQI meetings to ensure schedule is being followed and all components are addressed. 4. Executive Director and Maintenance Director are responsible for maintaining this system.

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 (8) Heating and Ventilation (8) HEATING AND VENTILATION SYSTEMS. An ALF must have heating and ventilation systems that comply with the building codes in effect at the time of facility construction. (a) TEMPERATURE. For all areas occupied by residents, design temperature for construction must be 75 degrees Fahrenheit. (A) An ALF must provide heating systems capable of maintaining 70 degrees Fahrenheit in resident areas. Required minimum temperatures are no less than 70 degrees Fahrenheit during the day and 60 degrees Fahrenheit during sleeping hours. (B) During times of extreme summer heat, fans must be made available when air conditioning is not provided. (C) Each unit must have individual thermostatic heating controls. (b) EXHAUST SYSTEMS. All toilet and shower rooms must be equipped with a mechanical exhaust fan or central exhaust system that discharges to the outside. (c) WALL HEATERS. Covers, grates, or screens of wall heaters and associated heating elements may not exceed 120 degrees Fahrenheit when they are installed in locations that are subject to incidental contact by individuals or with combustible material. Effective 01/15/2015 wall heaters are not acceptable in new construction or remodeling. (d) VENTILATION. Ventilation in each unit must occur via an open window to the outside, or with a mechanical venting system capable of providing two air changes per hour with one-fifth of the air supply taken from the outside. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit (F) when installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to: On 04/07/25, wall-mounted heaters were noted in resident one bedroom units. Heaters in three resident units (#104, #115, and #202) were tested by the surveyor reached temperatures above 200 degrees Fahrenheit on the wall heater cover grate. On 04/08/25 at approximately 11:15am, the need to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit was discussed with Staff 1 (ED) and Staff 5 (Maintenance Director). They acknowledged the findings. On 04/09/25, Staff 5 reported wall heaters in one bedroom units had been disconnected.

C640 - Heating and Ventilation 1. All cadet wall heaters have been disabled. 2. To prevent recurrence all cadet heaters will remain disabled. Inservice provided to care staff on safety precautions related to the cadet heaters. 3. Monthly during environmental walk through to ensure all cadet heaters are still disabled. 4. Executive Director will be responsible for maintaining this system

OAR 411-054-0300 (8) Heating and Ventilation (8) HEATING AND VENTILATION SYSTEMS. An ALF must have heating and ventilation systems that comply with the building codes in effect at the time of facility construction. (a) TEMPERATURE. For all areas occupied by residents, design temperature for construction must be 75 degrees Fahrenheit. (A) An ALF must provide heating systems capable of maintaining 70 degrees Fahrenheit in resident areas. Required minimum temperatures are no less than 70 degrees Fahrenheit during the day and 60 degrees Fahrenheit during sleeping hours. (B) During times of extreme summer heat, fans must be made available when air conditioning is not provided. (C) Each unit must have individual thermostatic heating controls. (b) EXHAUST SYSTEMS. All toilet and shower rooms must be equipped with a mechanical exhaust fan or central exhaust system that discharges to the outside. (c) WALL HEATERS. Covers, grates, or screens of wall heaters and associated heating elements may not exceed 120 degrees Fahrenheit when they are installed in locations that are subject to incidental contact by individuals or with combustible material. Effective 01/15/2015 wall heaters are not acceptable in new construction or remodeling. (d) VENTILATION. Ventilation in each unit must occur via an open window to the outside, or with a mechanical venting system capable of providing two air changes per hour with one-fifth of the air supply taken from the outside. This Rule is not met as evidenced by: