OAR 411-054-0025 (8) Facility Administration: Records (8) RECORDS. The facility must ensure the preparation, completeness, accuracy, and preservation of resident records. (a) The facility must develop and implement a written policy that prohibits the falsification of records. (b) Unless required or allowed by state or federal law, a facility shall not disclose any personally identifiable information regarding: (A) A resident’s sexual orientation; (B) Whether a resident is LGBTQIA2S+; (C) A resident’s gender transition status; or (D) A resident’s human immunodeficiency virus status. (c) The facility shall take appropriate steps to minimize the likelihood of inadvertent or accidental disclosure of information described in subsection (b) of this section to other residents, visitors or facility staff, except to the minimum extent necessary for facility staff to perform their duties. Facilities must notify residents or resident representatives if a resident is affected by a disclosure of information. (d) Resident records must be kept for a minimum of three years after the resident is no longer in the facility. (e) Upon closure of a facility, the licensee must provide the Department with written notification of the location of all records. Name: This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure facility records were accurate and not altered for 2 of 2 sampled residents (#s 1 and 6). Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 01/2021 with diagnoses which included insulin dependent diabetes. S/he was receiving home health services for catheter and wound care as of the survey. During the survey, from 04/21/25 through 04/24/25, resident records were either copied by the surveyor or provided to the survey team by facility staff. Two temporary service plans (TSPs) , provided to the surveyor by facility staff had been altered as follows: a. A TSP, dated 03/07/25, was copied by the surveyor on 04/21/25 after the entrance conference. The TSP noted the resident had symptoms of “positive covid test/return from hospital” and instructed staff to monitor and/or chart on “fever, dizziness, nausea/vomiting, falls.” On 04/23/25, staff provided the surveyor with a copy of the same TSP. However, the document had been altered and additional information (non-injury fall and instructions to monitor for bruising, bleeding, swelling) had been added. There was no reference that the additional documentation was a late entry nor date and/or initials of who added the information. b. A TSP for a non-injury fall and weakness, dated 03/08/25, was obtained by the surveyor on 04/23/25. The TSP contained signatures or initials of four staff, indicating they reviewed the document on 03/08/25. At 12:00 pm on 04/23/25, staff provided the surveyor with a copy of the same TSP. However, the document had been altered. Six additional staff signatures or initials had been added. Additionally, staff documented that they reviewed the information between 03/08/25 and 04/08/25. The altered documentation was shared with Staff 1 (Administrator), Staff 27 (Regional RN) and Staff 29 (Regional Director of Operations) on 04/24/25 at 12:57 pm. They acknowledged the findings. 2. Resident 6 was admitted to the facility in 04/2024 with diagnoses including lymphedema and arthritis. During the survey, from 04/21/25 through 04/24/25, resident records were either copied by the surveyor or provided to the survey team by facility staff. One temporary service plan (TSP) provided to the surveyor by facility staff had been altered as follows: A TSP for a brief change, dated 03/25/25, was obtained by the surveyor on 04/21/25 at 11:30 am. The TSP contained signatures of two staff, indicating they reviewed the document on 03/25/25 and 03/28/25. At 2:25 pm on 04/22/25, staff provided the surveyor with a copy of the same TSP. However, the document had been altered. Four additional staff signatures or initials had been added. Additionally, staff documented that they reviewed the information between 03/29/25 and 04/21/25. The altered documentation was shared with Staff 1 (Administrator), Staff 27 (Regional RN) and Staff 29 (Regional Director of Operations) on 04/24/25 at 12:57 pm. They acknowledged the findings.

C155 - Facility administration: Records 1. During survey it was identified that there are inaccurate or altered documents for resident #1 and resident #6. Resident #1-#6 files audited and updated to ensure accuracy. Community will develop and implement clear record policies - record creation, retention, and destruction. Protection against falsification of records, Privacy and HIPPA compliance. Ensuring the policy is reviewed annually and updated as needed. 2. Train all administrative and care staff on proper documentation practices, requirements of record handling and consequences of record falsification. This training will be included in onboarding and require annual updates. 3. Annual updates to policies will be completed by Executive Director, Health services Director, RN or designee to ensure policy is effective. 4. Executive Director, Health services director, RN or designee is responsible to see that the corrections are completed and monitored.

OAR 411-054-0025 (8) Facility Administration: Records (8) RECORDS. The facility must ensure the preparation, completeness, accuracy, and preservation of resident records. (a) The facility must develop and implement a written policy that prohibits the falsification of records. (b) Unless required or allowed by state or federal law, a facility shall not disclose any personally identifiable information regarding: (A) A resident’s sexual orientation; (B) Whether a resident is LGBTQIA2S+; (C) A resident’s gender transition status; or (D) A resident’s human immunodeficiency virus status. (c) The facility shall take appropriate steps to minimize the likelihood of inadvertent or accidental disclosure of information described in subsection (b) of this section to other residents, visitors or facility staff, except to the minimum extent necessary for facility staff to perform their duties. Facilities must notify residents or resident representatives if a resident is affected by a disclosure of information. (d) Resident records must be kept for a minimum of three years after the resident is no longer in the facility. (e) Upon closure of a facility, the licensee must provide the Department with written notification of the location of all records. Name: 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' needs, and provided clear direction regarding the delivery of care and services for 3 of 6 sampled residents (#s 3, 5, and 6) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 5 moved into the facility in 03/2023 with diagnoses including unspecified dementia. Observations of the resident, interviews with staff, review of the resident's most recent service plan dated 03/20/25, and temporary service plans (TSPs) showed the service plan did not provide clear direction to staff and/or was not reflective of the resident's needs in the following areas: * Two staff for transfers; * Mobility devices: use of a cane; and * Incontinence status and assistance needed. The need to ensure service plans were reflective of the resident's current care needs and provided clear direction to staff was discussed on 04/23/25 at 10:30 am with Staff 2 (RN), Staff 3 (LPN) and Staff 4 (LPN), and with Staff 1 (Administrator) and Staff 2 (RN) on 04/24/25 at 8:45 am. The findings were acknowledged. 2. Resident 3 was admitted to the facility in 08/2021 with diagnoses including vascular dementia and atrial fibrillation. Observations of the resident, interviews with resident and staff, review of the resident's service plan, dated 02/08/25, and progress notes, dated 01/21/25 to 04/22/25, were completed. The resident's service plan was not reflective and did not provide clear instruction to staff in the following areas: * Use of side rails, including safety checks and when to position up and down; * Instructions for oxygen use, including responsibility for cleaning and replacing supplies; * Non-pharmacological interventions for pain; * Instructions for bleeding precautions while on Eliquis (blood thinner); * Ability to communicate and be understood; and * Instructions regarding need for band aid on cheek. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed Staff 1 (Administrator), Staff 27 (Regional RN) and Staff 29 (Regional Director of Operations) on 04/25/25 at 12:20 pm. They acknowledged the findings. 3. Resident 6 was admitted to the facility in 04/2024 with diagnoses including lymphedema and arthritis. a. Observations of the resident, interviews with the resident and staff, review of the resident's service plan, dated 04/09/25, and progress notes, dated 02/06/25 to 04/22/25, were completed. The resident's service plan was not reflective in the following areas: * Bathing including the assistance needed, location and number of staff needed to assist; and * Dressing including the assistance needed and number of staff needed to assist. b. The resident's current service plan, dated 04/09/25, was not readily available to staff. The service plan available to staff was dated 01/03/25. The need to ensure service plans were available to staff and reflective of current care needs was discussed with Staff 1 (Administrator), Staff 27 (Regional RN) and Staff 29 (Regional Director of Operations) on 04/25/25 at 12:20 pm. They acknowledged the findings.

C260 - Service plan General 1. Resident #5 service plan updated to ensure the following items are included: - Two person assist with transfers - Mobility device assessment, include use of cane - Assistance with incontinent care and care as needed Resident #3 service plan updated to ensure the following items are included: -Side rail assessment including safety checks and when to position up and down -Instructions for O2 use including responsibility for cleaning and replacing supplies -Non pharmacological interventions for pain -Instructions for bleeding precautions while on Eliquis -Ability to communicate and be understood Instructions regarding need for band aid on right cheek Resident #6 service plan updated to ensure the following items are included: -Bathing assistance, time, date and number of staff required to assist -Dressing assistance, time, preference and number of staff required to assist -Updated service plan available to staff and is reflective of current care needs 2. Executive Director, LN, RCC or designee will review all remaining service plans to ensure accuracy, personalization and include resident specific care needs. Health services staff to complete training on service planning and TSP protocols 3. LN, RCC or designee will update service plan quarterly, RN to complete COC. Service plans will be reviewed and updated as needed at weekly Health Services meeting 4. Executive Director, LN, Resident care coordinator or designee is responsible to see that the corrections are completed and monitored.

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 determine what action or interventions were needed following short-term changes of condition, communicate the interventions to staff and document weekly progress until resolved for 4 of 6 sampled residents (#s 1, 4, 5, and 6) who experienced short-term changes of condition. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 04/2024 with diagnoses including lymphedema and arthritis. Review of clinical records including the service plan, dated 04/09/25, progress notes from 02/06/25 through 04/22/25, temporary service plans (TSPs) and outside provider notes revealed the following information: a. On 02/27/25 a Nurse Note from Staff 3 (LPN) indicated Resident 6 returned from the hospital with an S2 (pelvic) fracture without dislocation. Staff 3 documented the resident “has been in bed since returning from the hospital.” Interventions identified by Staff 3 included “Staff to float heels as tolerated in bed and offload/turn resident.” A TSP for “RFH [return from hospital] and Pelvic fracture”, dated 02/26/25, indicated Resident 6 “will need meal trays and extra help with ADL’s.” Included on the TSP was to chart “Pain, Pain and more pain” and “safety checks.” The nursing interventions to float heels and offload/turn resident in the Nurse Note were not included on the TSP from 02/26/25. During an interview with Staff 3 on 04/24/25 at 9:47 am, she acknowledged there was no documented evidence the interventions identified in the 02/27/25 Nurse Note were communicated to staff to be implemented. b. The following changes of condition lacked documentation of actions or interventions needed for the resident, communication of interventions to staff on all shifts, monitoring and progress noted at least weekly until resolution: * 02/14/25 - Fall with injury; and * 04/14/25 - Bruise to forehead during incontinence care. The need to ensure resident-specific actions or interventions for short-term changes of condition were determined, documented, and communicated to staff on each shift, with monitoring at least weekly through resolution was discussed with Staff 1 (Administrator), Staff 27 (Regional RN), and Staff 29 (Regional Director of Operations) on 04/24/25 at 12:20 pm. The findings were acknowledged. 2.Resident 1 moved into the facility in 01/2021 and had a history of falls. The resident's clinical record, including progress notes from 02/01/25 through 04/21/25, temporary service plans and the current service plan dated, 04/21/25, were reviewed, and interviews with the resident and staff were conducted. There was no documented evidence the facility consistently determined what resident-specific actions or interventions were needed, communicated the determined actions or interventions to staff, or documented weekly progress through resolution, or monitored previous fall interventions for effectiveness or consistent with evaluated needs and service plan for the following short-term changes of condition: * 02/08/25 - Fall; * 03/07/25 - Fall; and * 03/31/25 - Fall. The need to ensure resident-specific actions or interventions for short-term changes of condition were determined, documented, and communicated to staff on each shift, the changes of condition were monitored at least weekly through resolution, and fall interventions were monitored for effectiveness or consistent with evaluated needs and service plan was discussed on 04/23/25 at 10:10 am with Staff 2 (RN), Staff 3 (LPN) and Staff 4 (LPN), and with Staff 1 (Administrator) and Staff 2 (RN) on 04/24/25 at 8:50 am. The findings were acknowledged. 3. Resident 5 was admitted to the facility in 03/2023 with diagnoses which included high blood pressure and a stroke. Resident 5’s clinical record and progress notes dated 01/22/25 through 04/21/25 were reviewed and revealed the following: On 01/26/25, s/he was placed on alert because s/he "is having loose stools and c/o [complained of] lower abdominal pain…” The facility initiated short-term monitoring the same day. However, no monitoring until resolution was documented for the short-term change in condition. The need to ensure short-term changes of condition had documentation of weekly progress until resolution was discussed on 04/23/25 at 10:30 am with Staff 2 (RN), Staff 3 (LPN) and Staff 4 (LPN), and with Staff 1 (Administrator) and Staff 2 (RN) on 04/24/25 at 8:45 am. The findings were acknowledged. 4. Resident 4 moved into the facility in 10/2024 with diagnoses including hypertension and hemiplegia. The resident's current service plan dated 04/03/25, temporary service plans, progress notes dated 01/21/25 through 04/21/25, and corresponding incident reports were reviewed. Observations of the resident and interviews with caregivers were completed between 04/21/25 and 04/23/25. The resident experienced multiple short-term changes of condition as outlined: a. The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts and progress noted at least weekly through resolution: * 01/23/25 – Rash on thighs; * 01/24/25 – Non-injury fall; * 02/03/25 – Non-injury fall and subsequent injury fall; * 02/04/25 – Two non-injury falls; * 02/09/25 – Increase in trazodone; and * 02/26/25 – Increased anxiety. b. The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts: * 01/17/25 – Return to facility; and * 04/02/25 – Return to facility. The need to ensure resident-specific actions or interventions for short-term changes of condition were determined, documented, communicated to staff on each shift and the changes of condition were monitored, at least weekly, through resolution was discussed with Staff 1 (Administrator), Staff 27 (Regional RN), and Staff 29 (Regional Director of Operations) on 04/23/25 at 2:45 pm. The findings were acknowledged.

C270 - Change of condition and monitoring 1.Resident #6 record reviewed and updated to include RFH on 2/26, 2/14 fall with injury, 4/14 bruise to forehead. RN completed change of condition nurse note. Resident #1 record reviewed and updated to include interventions for fall on 2/8, 3/7, and 3/31. Resident #5 record reviewed and updated to include short term change of condition. Resident #4 record reviewed and updated to include actions and interventions for 1/23 rash on thighs, 1/24 NIF, 2/3 NIF, 2/4 2 NIF, 2/9 increase in Trazodone, 2/26 increased anxiety. RN completed short term COC documentation for 1/17 return to facility and 4/2 return to facility. 2. RN, LPN and Executive Director will review, monitor and update high risk resident charts weekly to ensure interventions, short term change of condition and significant change of condition documentation is complete. Health Services staff will complete Oregon care partner Monitoring change in condition course. 3. Executive Director, Health Services staff or designee will review 24 hour report and incident reports daily at stand up to identify change of condition. Weekly review of temporary service plans, wounds and chart notes will occur at weekly high risk meetings to identify any residents with change of condition. Health Services Director then follow up on these changes. 4. RN, Health services Director, Executive Director or designee is responsible to see that the corrections are completed/monitored.

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 significant change of condition assessment was completed by the RN, which included findings, resident status, and interventions, for 1 of 3 sampled residents (# 6) who experienced a significant change of condition for a pressure ulcer. Findings include, but are not limited to: Resident 6 was admitted to the facility in 04/2024 with diagnoses including lymphedema and arthritis. Progress notes dated 02/06/25 through 04/22/25 were reviewed, and the following was identified: Resident 6 experienced a Stage 2 pressure sore to his/her coccyx on 03/18/25. The pressure ulcer constituted a significant change of condition for which an RN assessment was required. During an interview on 04/23/25 at 10:57 am, Staff 2 (RN) acknowledged there was no RN assessment completed which documented findings, resident status, and interventions made as a result of the assessment. The need to ensure an RN assessment was completed for residents who experienced significant changes of condition was discussed with Staff 1 (Administrator), Staff 27 (Regional RN) and Staff 29 (Regional Director of Operations) on 04/25/25 at 12:20 pm. They acknowledged the findings.

C280 - Resident Health Services 1. Resident #6 record reviewed and updated to reflect change of condition 3/18 stage 2 pressure sore to coccyx. All short term and significant change of condition for residents will be monitored and reviewed weekly at high risk meeting. 2. Health services staff will complete Monitoring change in condition Oregon care partner course. Health services staff will be retrained on change in condion monitoring, documentation and reporting. 3. Health services will go over high risk resident list weekly. RN will complete short term and significant change of condition weekly and as needed. 4. RN, Health services Director, Executive Director or designee is responsible to see that corrections are completed and monitored.

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 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to coordinate on-site health services with outside services providers, to ensure staff were informed of new interventions, and the service plan was adjusted if necessary for 3 of 4 sampled residents (#s 1, 4, and 6) who received outside services. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 10/2024 with diagnoses including hypertension and hemiplegia. Progress notes, dated 01/21/25 to 04/21/25, outside agency services notes, dated 01/25/25 to 04/17/25, and the service plan, dated 04/03/25, were reviewed, and interviews with the resident and staff were conducted. There was no documented evidence staff were informed of the new instructions, and the service plan was updated for the following recommendation: * 04/14/25 - Home health PTA note stated, “Continue [plan of care] – Please encourage patient to attend facility’s [exercise] classes.” The need to ensure staff were informed of new interventions and the service plan was adjusted as necessary after on-site health services were provided was discussed on 04/23/25 at 2:35 pm with Staff 1 (Administrator), Staff 27 (Regional RN), and Staff 29 (Regional Director of Operations). The findings were acknowledged. 2. Resident 6 was admitted to the facility in 04/2024 with diagnoses including lymphedema and arthritis. Progress notes, dated 02/06/25 through 04/22/25, outside agency services notes, dated 01/16/25 to 04/23/25, temporary service plans, and the service plan, dated 04/09/25, were reviewed, and interviews with the resident and staff were conducted. There was no documented evidence staff were informed of the new instructions, and the service plan was updated with the following recommendations: * 03/05/25 - HH OT note indicated “SLUMS cognitive screening indicate mild stage of dementia-probably needs staff fo [sic] medication managing”; * 03/06/25 - HH RN note stated “[Resident 6] has a small red spot on R [right] heel. Needs heel to be floated daily to prevent Pressure ulcer”; * 03/25/25 - HH RN note indicated “Change Brief more Frequently during swing/NOC [night shift],” and * 04/10/25 - HH OT note stated, “*Please close door when cleaning up/pericare…”. The need to ensure staff were informed of new interventions and the service plan adjusted as necessary after on-site health services were provided was discussed on 04/24/25 at 12:20 pm with Staff 1 (Administrator), Staff 27 (Regional RN), and Staff 29 (Regional Director of Operations). The findings were acknowledged. 3. Resident 1 was admitted to the facility in 01/2021. The resident's clinical record, including progress notes from 01/01/25 through 04/21/25, temporary service plans (TSPs), the current service plan dated 04/21/25, and home health recommendations were reviewed, and interviews with the resident and staff were conducted. According to the resident’s clinical record, s/he was admitted to the hospital on 01/09/25 for concerns with red blood cell count and liver enzymes. S/he was discharged from the hospital on 01/13/25 and sent to a rehabilitation facility on 01/13/25. S/he returned to the facility on 02/07/25 with a Foley catheter in place and sacral wound. HH services were subsequently started for wound care. There was no documented evidence home health recommendations were communicated to staff, and/or the service plan adjusted for the following: * 03/11/25 - “Plenty [of] fluids intake” and * 04/01/25 - “Protein increase”, “reposition every 2 hours”, and “plenty of fluids.” Additional information was requested on 04/23/25. In an interview with Staff 2 (RN) on 04/23/25 at 11:00 am, she stated she had reviewed the home health documentation and “offered Ensure to [the resident] but [s/he] declined”. She added that she had not documented her conversation with the resident in the clinical record. The need to ensure staff were informed of new interventions made by outside providers, and the service plan adjusted, if necessary, was reviewed with Staff 1 (Administrator) and Staff 2 on 04/24/25 at 8:50 am. They acknowledge the findings.

C290 - On and off site Health Services 1. Community will develop an On & OFF site Provider Visit Policy to ensure all notes from all providers, including hospital visit notes are reviewed and new orders carried out in a timely manner. 2. Train all staff the process of handling On & OFF site Provider visit notes. 3. An annual review of the policy will be completed by Executive Director and Health Services Director or designee to ensure the process is effective or if it requires changes. 4. Health services Director, RN, LPN, Executive Director or designee is responsible to see that the corrections are completed and monitored.

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by:

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to follow established infection prevention and control protocols to ensure a safe, sanitary, and comfortable environment for 1 of 1 sampled resident (# 6) whose ADL care was observed. Findings include, but are not limited to: Resident 6 was admitted to the facility in 04/2024 with diagnoses including lymphedema and arthritis. A review of his/her current service plan and interviews with staff revealed s/he was dependent on staff for toileting tasks. The resident was currently bed bound and had a stage 2 pressure ulcer identified on his/her coccyx. On 04/23/25 at 12:49 pm, the surveyor observed two staff provide incontinence care for Resident 6 in bed. The resident was rolled to one side, a clean brief was placed under the soiled brief and the caregiver used wipes to clean the perineal area. The soiled brief was removed, not bagged and then tossed on the floor next to the resident’s bed. The caregiver used additional wipes to clean the perineal area and tossed the wipes on top of the soiled brief. The wipes rolled off and made contact with the carpeted floor. The resident was rolled to the opposite side, and staff determined the clean brief was dirty. After the perineal was cleaned with additional wipes, the second brief was removed, and the caregiver did not bag the brief prior to tossing it on the floor. Additionally, staff did not change gloves between “clean” and “dirty” tasks and were observed touching the resident’s sheets, blanket, draw sheet, and bed control with the same soiled gloves. The need to ensure infection prevention and control protocols were followed was discussed with Staff 1 (Administrator), Staff 27 (Regional RN), and Staff 29 (Regional Director of Operations) on 04/24/25 at 12:20 pm. The findings were acknowledged.

C295 - Infection Prevention and Control 1. The community has appointed a designee to be the Infectious Disease Specialist as the primary contact for infectious disease and infection control for our community. The designee will complete specialized training in infection prevention and control protocols unless the designee has received the specialized training within the 24-month period prior to the time of the designation. 2. Require newly hired employee to attend Pre-Service Infection Prevention and Control for Community-Based Care class; Require current employees to take the annual Infection Control and Prevention class. 3. Incorporate Infection Prevention and Control class in the new-hire training as it applies to the respective department. Current employees will also be trained. Annual updates to policies will be completed by Executive Director, Health Services Director or designee to ensure it is current according to OAR. 4. Infection control specialist, RN, Executive Director or designee is responsible to see that the corrections are completed and monitored.

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to implement effective methods of infection control for 1 of 1 sampled resident (#8). This is a repeat citation. Findings include, but are not limited to: Resident 8 was admitted to the facility in 2023 and had a history of chronic wounds. Observations and interviews with the resident and staff during the survey revealed s/he had a catheter, colostomy, relied on staff for several care needs, and had open sores on his/her buttocks area. On 08/06/25 at 8:45 am, the surveyor obtained permission and observed Staff 37 (CG) provide care to Resident 8. During the observation, Staff 37 said the bandages covering a wound on the resident’s buttock were soiled and needed to be changed. She called Staff 36 (MT) and requested assistance. Staff 36 (MT) entered the room at 8:55 am and was already wearing gloves. She put her hair in a ponytail and proceeded to initiate wound care wearing the same gloves. The surveyor intervened and asked Staff 36 to don clean gloves prior to performing wound care. Per the surveyor's request, Staff 36 donned clean gloves. During the wound care, the surveyor observed that Staff 36 was wearing a metal jewelry bracelet on her wrist that was not covered by the gloves. The bracelet had an approximate one-inch dangling section that touched the soiled bandages during the treatment. The above observation was discussed with Staff 1 (Administrator) at 9:25 am the same day. She acknowledged appropriate infection control practices were not implemented.

C0295 1. During survey revisit surveyor observed staff 36 (MT) enter residents apt already wearing gloves. MT put her hair in a ponytail and proceeded to attempt wound care. Surveyor intervened and instructed MT to don clean gloves prior to performing care. During wound care surveyor observed MT wearing a metal jewelry bracelet on her wrist that was not covered by gloves. MT notified ED of observation. LN re-trained MT on donning/doffing gloves. MT removed her bracelet and acknowledged appropriate infection control practices. 2. The system will be corrected so this violation will not happen again by scheduling mandatory in service infection control mentorship and supervision by Infection control specialist/LN. Competency re-evaluation to ensure proper technique. 3. This area will be evaluated during 30 day competency and annually thereafter. 4. RN, LN, Executive Director or designee is responsible to see that the corrections are completed and monitored.

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 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 staff instruction for 2 of 4 sampled residents (#s 3 and 5) whose medications were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 03/2023 and had diagnoses which included constipation. Review of the resident’s 04/01/25 through 04/21/25 MAR and PCP orders revealed the following: The resident had the following PRN bowel medications ordered for constipation: * Bisacodyl rectal suppository 10mg, one suppository PRN; * Glycerin one suppository PRN; * Docusol one suppository every day PRN; and * Polyethylene glycol powder one packet dissolved in 8 oz of water every day PRN. The MAR lacked a frequency for how often the Bisacodyl and Glycerin could be administered and lacked instructions to unlicensed staff for which PRN medication to administer first. During an interview on 04/23/25 at 10:30 am, Staff 2 (RN), Staff 3 (LPN) and Staff 4 (LPN) reviewed the MAR and confirmed the lack of parameters for the PRN bowel medications. The need to ensure the MAR contained resident-specific parameters and instructions for PRN medications was discussed with Staff 1 (Administrator) and Staff 2 on 04/24/25 at 8:45 am. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 08/2021 with diagnoses including vascular dementia and atrial fibrillation. The resident's MAR dated 04/01/25 through 04/21/25 and physician's orders were reviewed. The medication record did not include specific parameters and instructions for PRN medications, including the sequential order to administer PRN medications with the same reasons for use for the following: * Haloperidol for nausea and/or vomiting; * Ondansetron for nausea and/or vomiting; * Morphine for moderate to severe pain; and * Oxycodone for pain. The need to ensure MARs included instructions for PRN medications was discussed with Staff 1 (Administrator), Staff 27 (Regional RN), and Staff 29 (Regional Director of Operations) on 04/24/25 at 12:20 pm. The findings were acknowledged.

C130 Medication Administration 1. Skilled Nurse to add parameters to PRN medications and add, if applicable, the order in which medication is to be given first and so on. 2. Skilled Nurse to do a weekly PRN medication audit to ensure new medication orders are reviewed and parameters are added to the new PRN medication. 3. Skilled Nurse will evaluate area quarterly to ensure the process is effective or if it requires changes. 4. RN, Health services Director, Executive Director or designee is reponsible to see that the corrections are completed and monitored.

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 (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 observation, interview, and record review, it was determined the facility failed to ensure they accurately captured care time and care elements that staff were providing to each resident for 3 of 6 sampled residents (#s 4, 5 and 6) whose Acuity Based Staffing Tools (ABSTs) were reviewed. Findings include, but are not limited to: 1. Resident 5 moved into the facility in 03/2023 with diagnoses including a stroke and hemiplegia that affected his/her right side. Observations and interviews with the resident and his/her spouse, interviews with staff, review of the 03/20/25 service plan, temporary service plans (TSPs), and Resident 5’s ABST data was reviewed. The following areas were not reflective of the resident’s current ADL assistance: * Toileting and incontinence care; * Time responding to call lights; and * Two person transfer assistance. The need to ensure the ABST tool addressed the amount of staff time needed to provide care was discussed on 04/23/25 at 10:30 am with Staff 2 (RN), Staff 3 (LPN) and Staff 4 (LPN), and with Staff 1 (Administrator) and Staff 2 on 04/24/25 at 8:45 am. The findings were acknowledged. 2. Resident 4 moved into the facility in 10/2024 with diagnoses including hypertension and hemiplegia. The service plan, dated 04/03/25, temporary service plans, and the resident's corresponding ABST individual minutes were reviewed. The resident was observed, and interviews were conducted with staff. The resident's care time and care elements were found to not be reflective in the following areas: * Safety checks and fall prevention; and * Monitoring physical conditions or symptoms. The need to ensure the facility ABST accurately captured care time and care elements that staff were providing was discussed 04/23/25 at 2:50 pm with Staff 1 (Administrator), Staff 27 (Regional RN), and Staff 29 (Regional Director of Operations). The findings were acknowledged. 3. Resident 6 was admitted to the facility in 04/2024 with diagnoses including lymphedema and arthritis. The service plan, dated 04/09/25, temporary service plans, and the resident's corresponding ABST individual minutes were reviewed. The resident was observed, and interviews were conducted with staff and resident. The resident's care time and care elements were found to not be reflective in the following areas: * Personal hygiene; * Safety checks and fall prevention; * Responding to call lights; * Monitoring physical conditions or symptoms; * Providing treatments; * Repositioning in bed or a chair; * Bathing; * Bowel and bladder management; and * Dressing and undressing. The need to ensure the facility ABST accurately captured care time and care elements that staff were providing was discussed 04/24/25 at 12:20 pm with Staff 1 (Administrator), Staff 27 (Regional RN), and Staff 29 (Regional Director of Operations). The findings were acknowledged.

C362 Develop and maintain acuity-based staffing 1. Resident's #1 - #6 ABST reviewed and updated to reflect current needs. Resident #5 record reviewed and updated to reflect toileting and incontinence assistance, two person assist with transfers and time responding to call light. Resident #4 record reviewed and updated to reflect safety checks/fall interventions. Resident #6 record reviewed and updated to reflect personal hygiene, safety checks, fall prevention, responding to call lights, monitoring physical conditions or symptoms, providing treatments, repositioning in bed, bathing assistance, bowel/bladder management, dressing and undressing. 2. RCC and LPN will complete service plan update quarterly, RN will complete Change of condition care plan. Receptionist will schedule care plan meeting with resident, family or designee. Executive Director will complete service plan meeting and ensure ABST is updated. 3. Service plans and ABST will be reviewed at move in, quarterly updates and if a short term/significant change of condition arises. 4. RCC, LPN, RN, Executive Director or designee is responsible to see that the corrections are completed and monitored..

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 and reviewed whenever there was a significant change of condition or no less than quarterly at the same time the resident’s service plan was updated for 5 of 6 sampled residents (#s 1, 3, 4, 5, and 6). Findings include, but are not limited to: 1. Resident 4 moved into the facility in 10/2024 with diagnoses including hypertension and hemiplegia. The service plan, dated 04/03/25, progress notes, dated 01/21/25 to 04/21/25, and the resident’s corresponding ABST evaluation were reviewed. It was noted Resident 4 experienced a significant change of condition on 04/02/25 upon returning to the facility after a skilled nursing facility stay. However, the last ABST evaluation update for the resident was dated 11/16/24. The need to ensure the ABST was updated and reviewed whenever there was a significant change of condition was discussed on 04/23/25 at 2:55 pm with Staff 1 (Administrator), Staff 27 (Regional RN), and Staff 29 (Regional Director of Operations). The findings were acknowledged. 2. Resident 5 was admitted to the facility in 03/2023 with diagnoses including a stroke and hemiplegia that affected his/her right side. The service plan, dated 03/20/25, and the resident’s corresponding ABST evaluation were reviewed. The last ABST update for the resident was 11/16/24 and not updated quarterly. The need to ensure the ABST was updated and reviewed quarterly was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 04/24/25 at 8:45 am. The findings were acknowledged. 3. Resident 1 moved into the facility in 01/2021 and had diagnoses which included diabetes. S/he was receiving home health services as of the survey. The resident's clinical record, including progress notes from 01/01/25 through 04/21/25, temporary service plans, the current service plan dated 04/21/25, and home health recommendations were reviewed, and interviews with the resident and staff were conducted. According to the resident’s clinical record, s/he was admitted to the hospital on 01/09/25 and sent to a rehabilitation facility on 01/13/25. S/he returned to the facility on 02/07/25 with a foley catheter in place and sacral wound. This constituted a significant change in condition. The last ABST update for the resident was 11/16/24 and not updated with the significant change in condition. The need to ensure the ABST was reviewed and updated with significant changes in condition was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 04/24/25 at 8:50 am. The findings were acknowledged. 4. Resident 3 was admitted to the facility in 08/2021 with diagnoses including vascular dementia and atrial fibrillation. The service plan, dated 02/08/25, progress notes, dated 01/21/25 to 04/22/25, and the resident’s corresponding ABST evaluation were reviewed. The last ABST update for the resident was 11/16/24 and not updated quarterly. The need to ensure the ABST was updated and reviewed quarterly was discussed on 04/24/25 at 12:20 pm with Staff 1 (Administrator), Staff 27 (Regional RN), and Staff 29 (Regional Director of Operations). The findings were acknowledged. 5. Resident 6 was admitted to the facility in 04/2024 with diagnoses including lymphedema and arthritis. The service plan, dated 04/09/25, progress notes, dated 02/06/25 through 04/22/25, and the resident’s corresponding ABST evaluation were reviewed. It was noted Resident 6 experienced a significant change of condition on 02/27/25 for a pelvic fracture and again on 03/18/25 for a pressure ulcer. However, the last ABST evaluation update for the resident was dated 11/16/24. The need to ensure the ABST was updated and reviewed following a significant change of condition was discussed on 04/24/25 at 12:20 pm with Staff 1 (Administrator), Staff 27 (Regional RN), and Staff 29 (Regional Director of Operations). The findings were acknowledged.

C363 Acuity based staffing tool - updates and staffing plan 1. Resident #1 - #6 records reviewed. Resident #4 experienced change of condtion on 4/2/25. RN completed change of condition 4/17 and ABST updated to reflect current care needs. Resident #5 ABST updated and reflects current care needs. Resident #1 record/ABST reviewed and updated to reflect significant change of condition for 2/7/25. Resident #6 record/ABST reviewed and updated to reflect current care needs. RCC and LN will complete quarterly service plan review. RN will complete change of condition care plan. Executive Director will follow through to ensure care plan and ABST match current care needs. 2.RCC and LPN will complete service plan update quarterly, RN will complete Change of condition care plan. Receptionist will schedule care plan meeting with resident, family or designee. Executive Director will complete service plan meeting and ensure ABST is updated. 3. Service plans and ABST will be reviewed at move in, quarterly updates and if a short term/significant change of condition arises. 4. RCC, LPN, RN, Executive Director or designee is responsible to see that the corrections are completed and monitored..

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 (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 4 of 4 newly hired direct care staff (#s 16, 21, 24, and 25) demonstrated satisfactory performance in assigned duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed with Staff 8 (RCC) on 04/22/25 at 11:20am and again on 04/23/25 at 2:20pm. a. There was no documented evidence Staff 16 (MT) hired 03/18/25, Staff 21 (CG) hired 02/11/25, Staff 24 (MT) hired 01/27/25 and Staff 25 (MT) hired 10/23/24 demonstrated competency within 30 days of hire in the following areas: * Conditions that require assessment, treatment, observation and reporting; and * General food safety, serving and sanitation. b. There was no documented evidence Staff 24 demonstrated competency within 30 days of hire regarding providing assistance with ADLs. The need to ensure staff had documented evidence of competency demonstration within 30 days of hire was reviewed with Staff 1 (Administrator), Staff 27 (Regional RN) and Staff 29 (Regional Director of Operations) on 04/24/25 at 11:27 am. They acknowledged the findings.

C372 - Training within 30 days of hire 1. During survey it was discovered newly hired direct care staff #16, #21, #24, and #25 lacked competancy training, conditions that require assessment, treatment, observation and reporting, general food safety, serving and sanitation. Following staff will receive training on above topics. All training records will be reviewed to ensure trainings are completed. 2. Regional Director of Operations and Regional RN implemented training tool/report to ensure all training is updated and complete. 3. Bi-weekly audits to be completed by BOM and Department heads to ensure trainings are in compliance. 4. Department heads, Recruiter, Executive Director or designee is responsible to see that corrections are completed and monitored.

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 that 3 of 4 long-term direct care staff (#s 13, 17, and 20) completed 12 hours of annual training, including at least six hours related to dementia care and failed to ensure 1 of 4 long-term direct care staff (# 20) completed infectious disease training. Findings include, but are not limited to: Staff records were reviewed on 04/21/25 to 04/24/25 and the following was identified: a. There was no documented evidence Staff 13 (MT) hired 09/23/21, Staff 17 (CG) hired 07/16/21, and Staff 20 (CG) hired 04/18/23 completed a minimum of 12 hours of in-service training on topics related to the provision of care in community-based care settings and at least six hours of training based on their anniversary date of hire related to dementia care. b. There was no documented evidence Staff 20 completed annual infectious disease prevention training. The need to ensure direct care staff were trained annually on infectious disease outbreak and infection control and completed a minimum of 12 hours of in-service training on topics related to the provision of care in community-based care settings and at least six hours of dementia care training was reviewed with Staff 1 (Administrator), Staff 27 (Regional RN) and Staff 29 (Regional Director of Operations) on 04/24/25 at 11:27 am. They acknowledge the findings.

C374 - Annual and Biannual inservice for all staff 1. During survey it was discovered direct care staff #13, #17, and #20 did not complete 12 hours of annual training including 6 hours related to dementia care. Staff #20 lacked infectious disease prevention training. These staff will receive training on above topics. All training records will be reviewed to ensure training is completed. 2. Regional Director of Operations and Regional RN implemented training tool/report to ensure all training is updated and complete. 3. Bi-weekly audits to be completed by BOM and Department heads to ensure trainings are in compliance. 4. Department heads, Recruiter, Executive Director or designee is responsible to see that corrections are completed and monitored.

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 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to instruct residents in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building at least annually, with a written record of the content of the training sessions and the residents attending per the Oregon Fire Code (OFC). Findings include, but are not limited to: On 04/21/25 fire and life safety records were reviewed and revealed the following: There was no documented evidence the facility was providing instruction at least annually to residents regarding fire and life safety procedures and responsibilities. During an interview with Staff 6 (Plant Operations Manager) on 04/23/25 at 10:51 am, he stated he was unaware he had to re-instruct residents annually of fire and life safety procedures. In an interview with Staff 1 (Administrator) on 04/22/25 at 1:21 pm, she confirmed there was no annual re-instruction provided to residents. The need to re-instruct residents on fire and life safety at least annually as per the OFC requirements was discussed with Staff 1, Staff 6, Staff 27 (Regional RN) and Staff 29 (Regional Director of operations) at 11:20 am on 04/24/25. They acknowledged the findings, and no additional documentation was provided.

C422 - Fire and Life safety Training for residents 1. During survery it was discovered community lacked annual fire and life safety training for residents. Fire drill will be conducted and recorded per guidelines. 2. Staff conducting fire drills will be retrained on Powell Valley fire drill and safety policies, and CBC fire and life safety preparedness. Executive Director will work with Plant Operations team to ensure they are trained on fire life and safety policies and documentation. 3. Plant Operations team and Executive Director will review fire safety monthly during quality assurance meeting. 4. Executive Director, Plan Operations team or designee is responsible to see that corrections are completed and monitored.

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

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C295 and C610.

C0455 Refer to C295 and C610

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by:

OAR 411-054-0300 (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 maintain exterior pathways in good repair and store garbage in covered refuse containers. Findings include, but are not limited to: On 04/24/25 at 10:51am, during a walk-through of the facility with Staff 1 (Administrator) and Staff 6 (Plant Operations Supervisor) the following was identified: a. There were multiple uneven pavement seams noted throughout the courtyard, especially around the water feature and the outdoor dining area. There were also uneven areas noted on the public concrete walkway near the main entrance to the building and near the rose garden. This uneven pavement created potential trip hazards for residents. b. There was approximately 20 feet of pathway outside Room 118 and next to the green metal mechanical access box with path drop-offs that ranged in depth from three inches to five inches. The drop-offs posed a potential fall hazard for residents. c. Garbage dumpsters were left open through the survey period of 04/21/25 to 04/24/25 with bags of food waste and trash exposed. The need to ensure all exterior pathways were maintained in good repair and garbage was stored in covered refuse containers was reviewed with Staff 1 and Staff 6 at 11:19 am on 04/24/25. They acknowledged the findings.

C610 - General building exterior 1. During survey it was identified that the community lacked the need to ensure all exterior pathways were maintained in good repair and garbage was stored in covered refuse containers. Plant Operations manager and Executive Director will work together to have Plant operations team or 3rd party company complete corrections. 2. Plant Operations manager and Executive Director will review policy and procedure for general building exterior during monthly Safety committee meeting. 3. General building exterior policy and procedure will be reviewed and updated annually to ensure accuracy with OAR's. 4. Plant Operations manager, Executive Director or designee is responsible to see that corrections are completed and monitored.

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 maintain all exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways in good repair and free from drop-offs to mitigate potential tripping hazards. This is a repeat citation. Findings include, but are not limited to: On 08/05/25 through 08/06/25 the exterior walking paths and courtyard were toured, and the following was identified: * There were multiple uneven concrete seams noted throughout the courtyard and along the walking path from the front main entrance to the back of the building; * Multiple residents were observed using the courtyard and the walking path during the survey; and * There were multiple areas along the walking path from the rose garden to the back of the building that had drop-offs between two and five inches. During an interview on 08/05/25 at 9:47 am, Staff 33 (Plant Operations Supervisor) toured the exterior courtyard and the walking path from the front entrance to the back of the building. Staff 33 reported he was working on drop-offs surrounding the resident unit patios but hadn’t finished yet. During a walkthrough of the courtyard, Staff 33 stated, “I get it, the boards [placed in the seams of the concrete] are bowing and still create a tripping hazard. I don’t like it; the boards need to come out and aggregate cement put in.”? The exterior walking paths and courtyard were toured with Staff 1 (Administrator) on 08/06/25 at 12:50 pm. She acknowledged the findings.

C0610 1. During survey revisit surveyor observed multiple uneven concrete seams throughout the courtyard and along the walking path from the main entrance to the back of the building. There were multiple areas along the walking path from the rose garden to the back of the building that had drop offs between two to five inches. Plant Operations Director is filling and leveling multiple concrete seams throughout courtyard, walkways and behind community. A truck load of soil was delivered to community to fill in drop offs areas, surveyor observed parking site with soil. 2. Plant Operations Director, Plant Operations tech and Executive Director will complete walk through of grounds weekly to ensure areas that require concrete work have warning signs or high visibility paint. Topic will be included in monthly resident council meeting. 3. This area will be evaluated monthly until all spots are cleared then, annually thereafter. 4. Plant Operations Director, Executive Director or designee are responsible to see that the corrections are completed and monitored.

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 interior and exterior materials and surfaces and all equipment necessary for the health, safety, and comfort of the residents was kept clean and in good repair. Findings include, but are not limited to: Observations of the facility on 08/06/25 revealed the following: a. Gouged and scraped doors were observed in the following areas: * Multiple resident rooms on the second and third floors; * First floor office and doors leading to library; * Stairwell doors; * Equipment room door; * Sprinkler Valve room door; * Exit doors to courtyard; * Beauty shop; * Exit doors near first floor women’s common bathroom and Room 123; and * Laundry rooms. b. Carpet stains were observed in stairwells, hallways on all three floors, and the first-floor library. c. Scraped paint was observed on corner guards near the elevators on all three floors. d. The dining room had scraped and gouged areas in the wood on several walls, baseboards, and pillars. e. Sitting benches in the front entrance, near the beauty shop, and on the third floor near Rooms 117, 121, and 302 had scraped legs. f. Stained seat cushions were observed on the following: bench near Room 338, chairs in sitting area near the beauty shop, and two chairs near the table in the library. g. Stairs, located in the stairwell on the east wing, had two frayed, open areas that were approximately 2X3 inches. h. The elevator located near the beauty shop had an approximate 6X2 inch section missing from the interior paneling. The surveyor toured the environment with Staff 1 (Administrator) on 08/06/25 at 2:00 pm. She acknowledged the findings.

C0614 1. During survey revisit surveyor observed gouged and scraped doors, carpet stains, scraped paint on corner guards, scraped/gouged areas in the dining room, scraped legs on sitting benches, stained seat cushions, stairs on east hallway with frayed areas, 6x2 inch section missing from panel in elevator located near beauty shop. Community hired Alameda cleaners to complete cleaning of carpets and upholstery. Plant Operations team is order elevator panel and sanding down, painting or replacing doors with scrapes/gouged areas. 2. Plant Operations Director, Community relations Director and Executive Director will complete walk through weekly to ensure areas that require maintenance are identified and a work order is issued. 3. This area will need to be corrected or evaluated quarterly. 4. Plant Operations team, Housekeeping, Executive Director or designee are responsible to see that the corrections are completed and monitored.

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:

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 exceed 120 degrees Fahrenheit (F) when they were installed in locations that were subject to incidental contact by individuals or with combustible material. Findings include, but are not limited to: On 04/21/25 the building was toured. At approximately 9:55 am, an electric wall heater was observed in Room 227. Using a digital thermometer, the grate of the wall heater was measured at 161.9 degrees F. A wooden basket containing a knitted blanket was pressed against the grate and had to be moved to obtain the temperature. With prolonged heater use, the blanket posed a potential fire hazard. A plan of action was requested on 04/21/25 at 11:35 am. Staff 1 (Administrator) provided the plan at 2:42 pm on 04/21/25. It was confirmed all electric wall heaters that were out of compliance were disconnected on 04/22/25 at 12:05 pm. On 04/24/25 at 11:19 am, the need to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees F when they were installed in locations that were subject to incidental contact by individuals or with combustible materials was reviewed with Staff 1 and Staff 6 (Plant Operations Supervisor). They acknowledged the findings.

C640 - Heating and ventilation 1. During survey it was identified multiple wall-mounted electric heaters (installed in 2020) were observed operating at a surface or output temperature exceeding 120 degrees, which is above safe or regulated threshold for this environment. Power to the units were shut off as a safety precaution. 4/21/25 Plant Operations team conducted audit of all AL heating units. 2. Plant Operations manager will conduct routine audits and include temperature logs in quality assurance processes. Plant operations manager and Executive Director will develop or revise Hot water temperature monitoring policy. 3. Plant Operations team will complete testing of wall mounted electric heater monthly to ensure surface and output temperature does not exceed 120 degrees. 4. Plant Operations team, Executive Director or designee is responsible to see that corrections are completed and monitored.

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: