OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed, for 2 of 4 sampled residents (#s 2 and 3) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the community in 02/2021 with diagnoses including anxiety disorder, delirium and atrial fibrillation. Resident 2’s clinical record was reviewed, including progress notes dated 01/17/25 through 04/28/25, and physician orders. The resident had a signed physician order dated 04/22/25 for a diet order change to “…chopped, and use gravy/sauce over meat and eggs…” A progress note dated 04/22/25 documented, “New diet order to chop foods, use gravy/sauce for meat and eggs…Care plan updated and orders added.” On 04/30/25 Resident 2 was served scrambled eggs without gravy for breakfast. Staff 19 (Assistant Dining Manager), who was plating breakfast, reported resident wasn’t given gravy because “we don’t have gravy for breakfast.” Multiple staff members reported they had never seen Resident 2 receive gravy on his/her eggs. In an interview on 4/30/25, Staff 3 (LPN) reported she had received the order and documented the changes for clinical and caregiving staff but did not know she needed to notify the kitchen. Staff 1 (Administrator) confirmed that the kitchen did not know about the diet change order. The need to ensure physician orders were carried out as prescribed was discussed with Staff 1, Staff 3, Staff 21 (RCC), and Witness 1 (RN Consultant) on 04/30/25. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 10/2024 with diagnoses including heart disease. The resident’s vital signs, flow sheets, 04/01/25 through 04/28/25 MAR and the 03/11/25 signed physician orders were reviewed and showed the following: *Daily weights were ordered for the resident and any loss or gain of three pounds, or more was to be reported to the physician. *On 12 occasions daily weight documentation showed a three pound or greater weight change. The information was not reported to the resident’s physician as ordered. The need to follow physician’s orders including reporting parameters was discussed with Staff 1 (Administrator), Staff 3 (LPN), Staff 21 (RCC) and Witness 1 (RN Consultant) on 04/29/25. The staff acknowledged the findings.

Resident #2 diet order was given to the dietary manager for implementation on 4/30/25. Resident #3 weight change of 3 pounds or greater has been reported to physician. Review of all other residents who have daily weights ordered were reviewed to ensure parameters are being reported as ordered to their physician. Licensed nurse or designee will provide education to all nursing staff on following physician orders and reporting out of range parameters per MD orders. Administrator to provide education to dietary and nursing staff on how to submit diet order changes to the dietary department. All diet changes are to be communicated to the nursing staff via temporary service plan. Diet orders will be reviewed through the 24-hour clinical chart review process by the Administrator and Licensed Nurse. Daily weight worksheet has been implemented and will be reviewed by the Licensed Nurse and/or Administrator daily during the 24-hour clinical chart review to ensure out of range parameters have been faxed to physician per orders. The Administrator and/or Licensed Nurse will be responsible for ensuring physician orders are followed.

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 keep all interior surfaces in good repair. Findings include, but are not limited to: The interior of the building was toured on 04/29/25 at 9:45 am. The following areas were in need of cleaning or repair: * There were deep scrapes and gouges on the wood fire doors on the first and second floors; * Doors and door frames of multiple resident apartments showed scratches and damage to wood surfaces; * Dark marks and scrapes were observed on walls in the second floor laundry room; * There were holes, stains, and damage to ceiling panels in multiple areas; * Dark scratches and marks on multiple table legs in the dining room; * Activities room on the second floor had a storage frame with rough, unpainted wood; and * The window sill in the activities room was damaged, with bare wood exposed. On 04/30/25, the need to maintain interior surfaces clean and in good repair was discussed with Staff 1 (Administrator) and Staff 4 (Maintenance). They acknowledged the findings.

Administrator/Maintenance Director have done walk through in all spaced indentified areas of need of improvement. Work order have been put in place to be corrected. Supplies are being ordered to perform work orders. - Affected doors and window sill will be refurbished. - Affected walls, door frames, and activity storage frame, will be repainted - Damaged ceiling tiles will be repaired or replaced. - Affected dining room tables to be refurbished. Monthly Environmental Walk through with Administrator and Maintenance Director - Administrator and Maintenance Director responsible for correcting and monitoring.