OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to promptly investigate incidents to rule out abuse, or immediately report abuse and suspected abuse to the local SPD (Seniors and People with Disabilities) office for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) whose records were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 10/2021 with diagnoses including vascular dementia and generalized anxiety. a. The resident’s 02/05/25 to 05/02/25 progress notes identified the following incidents of abuse: * 03/01/25 – The resident “exhibited aggressive behaviors” and called three other residents names. * 03/09/25 – The resident “has been aggressive” and swearing at other residents. * 03/16/25 – “[Resident] had a pretty bad behavior day... [s/he was seen] rubbing another residents [sic] thigh…” * 04/29/25 – “[Resident]…started calling [another resident] names which upset [him/her]. In an interview on 05/06/25, Staff 1 (ED) stated she was not aware of these incidents of abuse and that they had not been reported to the local SPD. On 05/07/25 Staff 1 provided documentation of investigations for these incidents of abuse and a copy of the self-report to the local SPD office. b. During the entrance interview on 05/05/25, it was reported Resident 1 “kissed and groped” Resident 3. There was no documentation of this incident in Resident 1’s and Resident 3’s records. In an interview on 05/06/25 Staff 2 (RCC) reported she was aware of this incident but did not know if it had been reported. The facility was unable to provide documentation of this incident of abuse being reported to the local SPD. On 05/07/25 Staff 1 provided documentation of an investigation and self-report to SPD, completed 05/06/25. The facility’s failure to immediately report all incidents of abuse to the local SPD office was discussed with Staff 1 and Staff 2 on 05/07/25. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 04/2025 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's 04/01/25 care plan, 04/02/25 through 05/03/25 progress notes, “Temporary Service Plans,” incident investigations and physician communications were completed. The resident required total staff assistance for meal intake and two staff assistance for all ADL care. The resident was not able to consistently make needs known and would no longer initiate any care needs. The resident’s cognition and physical condition had declined significantly over the last several weeks. Review of the resident's records showed the following: * An incident investigation, dated 04/05/25, indicated the resident experienced an unwitnessed fall and sustained a head injury and a skin tear to the right elbow. The resident could not say what occurred. The fall with injury was not reported to the local SPD office. * An incident investigation, dated 04/07/25, indicated the resident experienced an unwitnessed fall and sustained a laceration and a dislocation to fingers on the left hand. The resident could not offer any information. The fall with injury was not reported to the local SPD office. In interviews between 05/05/25 and 05/07/25, Staff 1 (ED) and Staff 2 (RCC) indicated the incidents were not reported at the time of the injuries. A confirmation that the falls with injuries were reported to the local SPD office was provided to the survey team prior to exit. The need to ensure incidents were reported to the local SPD office when required was discussed with Staff 1 and Staff 2 on 05/07/25. The staff acknowledged the findings. 3. Resident 4 was admitted to the facility in 03/2025 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's 03/12/25 care plan, 03/12/25 through 05/01/25 progress notes, “Temporary Service Plans,” incident investigations and physician communications were completed. The resident required staff assistance for all ADL care. The resident was not able to consistently make needs known and required frequent cueing and redirection toward needed tasks. Review of the resident's records showed the following: * An incident investigation, dated 03/16/25, indicated the resident had an altercation with his/her roommate (Resident 5). Resident 4 was hit in the head with a cane and sustained a head injury. The incident investigation was incomplete. The altercation was not reported to the local SPD office. * A progress note, dated 03/18/25, indicated the resident had an altercation with another resident. Resident 4 touched the other resident’s genitals. The resident-to-resident altercation was not investigated. The altercation was not reported to the local SPD office. * A progress note, dated 03/19/25, indicated the resident had an altercation with another resident. Resident 4 touched the other resident’s thigh. The resident-to-resident altercation was not investigated. The altercation was not reported to the local SPD office. * A progress note, dated 03/19/25, indicated an unsampled resident’s family reported that their family member (a resident) stated Resident 4 entered his/her apartment and attempted to touch the resident. Resident 4 was kicked at by the unsampled resident and made to leave. The resident-to-resident altercation was not investigated. The altercation was not reported to the local SPD office. * A progress note, dated 03/22/25, indicated the resident had experienced an unwitnessed fall and sustained a skin tear. The fall with injury was not investigated nor reported to the local SPD office. * A progress note, dated 03/23/25, indicated the resident had an altercation with an unsampled resident. Resident 4 grabbed the unsampled resident’s walker and would not let go. Staff were eventually able to get the resident to release the walker. The resident-to-resident altercation was not investigated or reported to the local SPD. * A progress note, dated 03/28/25, indicated Resident 4 entered another resident’s apartment. The progress note did not provide information on any interaction with the resident who resided in the apartment or any touching that may have occurred. The resident-to-resident altercation was not investigated or reported to the local SPD office. * A progress note, dated 04/07/25, indicated the resident was found with an injury of unknown cause, a bruise found on the resident’s left arm. The resident could not offer any information on what occurred. The injury of unknown cause was not investigated or reported to the local SPD office. In interviews between 05/05/25 and 05/07/25, Staff 1 (ED) indicated she was not yet working at the facility and could not say why the incidents were not investigated or properly reported. A confirmation that the incidents were reported to the local SPD office was provided to the survey team prior to exit. The need to ensure incidents were investigated promptly to rule out abuse and neglect and reported to the local SPD office when required, was discussed with Staff 1 and Staff 2 on 05/07/25. The staff acknowledged the findings.

1. Every Progress Note that Med Techs put into the system regarding Residents 1,2,3,4 and 5. They have to message the ED with what they put into the prog note. to determine if it needs to be an incident report or reported. 2. Going forward, all MT's have to message the ED with the progress notes they put into the system for each shift, everyday so i can advise them on next steps needed and i can be aware of what needs to be reported. 3. Evaluation will be Daily During Clinical, with ED and RCC, when we go over every Prog note from the previous 24 hours. 4. ED will be responsible to make sure that these corrections are being implemented and followed through on.

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

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements and were completed prior to the resident being admitted to the facility for 2 of 2 sampled residents (#s 2 and 5) whose move-in evaluations were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 04/2025 with diagnoses including dementia. The resident's new move-in evaluation was completed on 03/25/25. The following elements were not addressed or had conflicting information in the move-in evaluation: * Customary routines related to eating and bathing; * Interests, hobbies, social and leisure activities; * Memory, confusion and decision making abilities; * Personality, including how the person copes with change or challenging situations; * Speech; * Pronouns and gender identity; * How does the person express pain; * Nutrition habits, fluid preferences and weight if indicated; * Fall risk or history; * Alcohol and drug use; and * Environmental factors that impact the resident’s behaviors. The need to complete move-in evaluations prior to a resident being admitted to the facility and to address all required elements was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. The staff acknowledged the findings. 2. Resident 5 was admitted to the facility in 03/2025 with diagnoses including dementia. The resident's new move in evaluation was undated and unsigned. The following elements were not addressed or had conflicting information on the move-in evaluation: * Customary routines related to sleeping, eating and bathing; * Interests, hobbies, social and leisure activities; * List of current diagnoses; * List of medications and PRN use; * Visits to health practitioner(s), ER, hospital or NF in the past year; * Behavioral problems; * Memory, confusion and decision making abilities; * Speech; * Personal hygiene; * Transfers and assistive devices; * Ability to manage medications; * Ability to use call system; * Transportation; * Pronouns and gender identity; * How does the person express pain; * Nutrition habits, fluid preferences and weight if indicated; * Fall risk or history; * Alcohol and drug use; * Emergency evacuation ability; * History of dehydration; * Recent losses; * Elopement risk or history; * Alcohol and drug use; and * Environmental factors that impact the resident’s behaviors. The need to complete move-in evaluations prior to a resident being admitted to the facility and to address all required elements was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. The staff acknowledged the findings.

1. Previously before i came on the RCC was doing the evaluations. For Residents #2 and #5 and new evaluation will be done on them to reflect everything needed. 2.Going forward the ED will re train the RCC and ADmin assist on Evaluations and implement a new move in checklist for each department. The new checklist will include everything that is needed before move in and at move in for each individual Department and signed off on by the ED at Move in. 3. Every 90 days the check lsit will be evaluated for new needs or improvements. 4. ED will check the check list before move in date and right after move in date to ensure completion.

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by:

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction for staff, were consistently implemented by staff and readily available for staff review for 4 of 4 sampled residents (#s 1, 2, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 04/2025 with diagnoses including dementia. Observations of the resident, interviews with staff and review of the care plan, dated 04/01/25, showed the care plan was not reflective of the resident's current care needs, was not consistently implemented and/or did not provide clear direction to staff in the following areas: * Safety interventions including low bed, fall mats and side rail use; * Meal assistance; * Safety checks; * Fluid placement and keeping over bed table in reach; * Dressing, hygiene and grooming assistance; * Transfers, incontinent care and skin care; * Catheter care; and * Bed mobility and position changes. The need to ensure resident care plans were reflective of current care needs, were consistently implemented, provided clear direction to staff and were available for care staff was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. The staff acknowledged the findings. 2. Resident 4 was admitted to the facility in 08/2020 with diagnoses including dementia. Observations of the resident, interviews with staff and review of the care plan, dated 03/27/25, showed the care plan was not reflective of the resident's current care needs, was not consistently implemented and/or did not provide clear direction to staff in the following areas: * Safety checks; * Nighttime checks; * Dressing, hygiene and grooming assistance; * Toileting and incontinent care; and * Proper footwear. The care plan binder did not contain all resident care plans for staff review. Eight care plans were not located in the binder including Resident 4’s care plan. The other available information was locked in the medication room. The need to ensure resident care plans were reflective of current care needs, were consistently implemented, provided clear direction to staff and were available for care staff was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. The staff acknowledged the findings. 3. Resident 5 was admitted to the facility in 03/2025 with diagnoses including dementia. Observations of the resident, interviews with staff and review of the care plan, dated 03/12/25, showed the care plan was not reflective of the resident's current care needs, was not consistently implemented and/or did not provide clear direction to staff in the following areas: * 1- versus 2- staff assistance, fall interventions and safety checks; * Dressing, hygiene and grooming assistance; * Excessive call light use; * Meal assistance and cueing; * Nonskid footwear and gait belt use; * Sexual behaviors, wandering and grabbing other residents/belongings; and * Toileting, bathing and incontinent care. The care plan binder did not contain all resident care plans for staff review. Eight care plans were not located in the binder including Resident 5’s care plan. The other available information was locked in the medication room. The need to ensure resident care plans were reflective of current care needs, were consistently implemented, provided clear direction to staff and were available for care staff was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. The staff acknowledged the findings. 4. Resident 1 moved into the facility in 10/2021 with diagnoses including vascular dementia and generalized anxiety disorder. The resident’s care plan dated 03/27/25 was reviewed, observations were made, and interviews were conducted. The resident's care plan was not reflective of the resident’s needs and did not provide clear direction to staff regarding the delivery of services in the following areas: * Romantic relationship with another resident; and * Safety checks. The need to ensure care plans were reflective of the residents’ needs and provided clear instruction to staff was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. They acknowledged the findings.

1: A full review of residents 1,2,4 and 5's care plans will be done and updated to their current needs and provide clear insturctions for each section. 2. ED implemented a Care Giver Care Plan information sheet, that the direct staff fill out with all information and needs they are currently doing for the residents.. Going forward, every quarter when a Care Plan is due for Review, the week before ED will put of the information sheet for Care givers to fill out and gather all apparopriate information needed to ensure Accuracy. 3. Every 90 days, every move in or every SCOC. 4. ED will be responsible for making sure that all Care Plans get updated effectivley and within Compliance.

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 and document what action or intervention was needed for a resident following a short-term change of condition, communicate determined interventions to staff on each shift, monitor the effectiveness of the interventions consistent with the evaluated needs of the resident, and/or monitor and document weekly progress until the condition resolved for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) who experienced falls, had changes of condition, or who required monitoring. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 10/2021 with diagnoses including vascular dementia and generalized anxiety disorder. The resident’s progress notes dated 02/05/25 through 05/05/25, and care plan dated 03/27/25 were reviewed, observations were made, and interviews with staff were conducted. a. During the entrance interview on 05/05/25 Resident 1 was identified as having “kissed and groped” Resident 3. There was no documented evidence the facility had determined interventions for this incident, had communicated interventions to staff, and had monitored the situation until resolution according to the needs of Residents 1 and 3. In an interview on 05/06/25 Staff 1 (ED) reported that she was unaware of the incident of and acknowledged that the facility had not determined interventions and monitored Residents 1 and 3. b. During the entrance interview on 05/05/25 Resident 1 was identified as having a special friendship with an unsampled resident and had been observed recently with his/her arm around the unsampled resident. Throughout the survey Resident 1 was observed having meals with the unsampled resident at a table for two. A photo of the two residents together was hung outside Resident 1’s apartment, and multiple staff reported that the residents were “boyfriend and girlfriend.” There was no documented evidence the facility had developed appropriate interventions for this relationship and were monitoring for ongoing evidence of consent. Staff 1 reported in an interview on 05/07/25 that she had observed Resident 1 and the unsampled resident holding hands. She acknowledged that the facility was not monitoring the two residents according to their needs. The need to ensure the facility determined and documented what actions or interventions were needed for a resident and monitored the resident and documented on the progress of the condition at least weekly until resolved following a change of condition was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. They acknowledged the findings. 3. Resident 2 was admitted to the facility in 04/2025 with diagnoses including dementia. The resident's 04/01/25 care plan, 04/02/25 through 05/03/25 progress notes, incident investigations and physician communications were reviewed. The resident experienced multiple short-term changes without noted progress at least weekly until resolved, and/or lacked resident-specific directions to staff in the following areas: * Medication changes; * Urinary tract infection and antibiotic use; * Injury and non-injury falls; * Skin injuries; * Seizure activity; * Emergency room visits; and * Vomiting. The need to ensure short-term changes of condition had documentation of weekly progress until resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. The staff acknowledged the findings. 4. Resident 4 was admitted to the facility in 08/2020 with diagnoses including dementia. The resident's 03/27/25 care plan, 02/05/25 through 03/18/25 progress notes, incident investigations and physician communications were reviewed. Additional progress notes were requested after 03/18/25, and no additional notes were provided. The resident experienced short-term changes without noted progress at least weekly until resolved, and/or lacked resident-specific directions to staff in the following areas: * Resident-to-resident altercation. The need to ensure short-term changes of condition had documentation of weekly progress until resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. The staff acknowledged the findings. 5. Resident 5 was admitted to the facility in 03/2025 with diagnoses including dementia. The resident's 03/12/25 care plan, 03/12/25 through 05/01/25 progress notes, incident investigations and physician communications were reviewed. The resident experienced multiple short-term changes without noted progress at least weekly until resolved, and/or lacked resident-specific directions to staff in the following areas: * Medication changes; * Skin injuries and a head wound; * Resident-to-resident altercations; * Aggressive behaviors, hitting glass, throwing items; * Sexual behaviors; and * Falls and placing self on the floor. The need to ensure short-term changes of condition had documentation of weekly progress until resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. The staff acknowledged the findings.

1. For residents 1,2,3,4 and 5. All notes will be reviewed and any Significant or short term needs will be immediatley addressed and charted on. 2. ED and RCC to review daily in Clinical to ensure any and all changes in a resdient are noted and documented on appropriatley. 3. Daily during Clinical. To ensure it is being filled out and all changes are noted for. 4. ED will be responsible for making sure this is completed and any changes are sent to the RN for Review and COC's needed.

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 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed by a physician or other legally recognized practitioner for 1 of 3 sampled residents (#1) whose orders were reviewed. Findings include, but are not limited to: Resident 1 moved into the community in 10/2021 with diagnoses including vascular dementia and generalized anxiety disorder. During the entrance interview on 05/05/25, Resident 1 was identified as receiving palliative care services which included regular visits from a nurse practitioner. An “Outside Agency Documentation” sheet dated 02/20/25 documented a signed order from the nurse practitioner: “Please repeat blood pressure. If after lisinopril SBP >150 and [sic] notify me.” Review of the resident’s vital records log identified 18 days between 02/21/25 and 03/20/25 that Resident 1’s blood pressure was not rechecked. The need to ensure physician or legally recognized practitioner orders were carried out as prescribed was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. They acknowledged the findings.

1. For Resdient 1, a full review of his MAR and doctors orders will be completed and staff will be made aware of what is expected according to any doctors orders. 2. Full Training for every Med Tech that is currently on the cart. To include going over every section of the skills checklist with the RCC to ensure compentancy of every section. 3. Every Quarter, (90days) of employment. 4, RCC to ensure completeion of quartley skills assesment and ED to review once completed by RCC.

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

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused consent to an order for medication and treatment administration for 1 of 1 sampled resident (# 5) who was reviewed with documented refusals. Findings include, but are not limited to: Resident 5 was admitted to the facility in 03/2025 with diagnoses including dementia. The resident's 04/01/25 through 05/05/25 MAR and signed physician orders dated 03/11/25 were reviewed. The following medications were documented as refused between 04/01/25 and 05/05/25: * Calmoseptine (skin cream), was refused on 41 occasions; * Propranolol (blood pressure medication used out of class for anxiety/agitation for this resident), was refused on 14 occasions; * Fluticasone (nasal spray), was refused on 13 occasions; and * Eliquis (blood thinner), was refused on nine occasions. There was no documented evidence the prescriber was notified after each refusal for the above medications/treatments. The need to notify the physician or other practitioner of resident medication refusals was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. The staff acknowledged the findings.

1. For resdient #5, the doctor will be faxed to include that last 90 days of refusals. 2. New Med Tech end of shift Checklist to be created to include making sure Doctors are faxed for specific reasons including refusal of medications. Also to include which room refused. 3. Every day in clinical., ED and RCC will go over end of shift checklist and compare with sent faxes to ensure doctors are being reported too. 4. ED will be responsible for ensuring this is completed daily by every med tech and following up with corrections needed.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by:

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate and included resident-specific parameters and instructions for PRN medications for 2 of 3 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 10/2021 with diagnoses including vascular dementia and generalized anxiety disorder. Review of Resident 1's 04/01/25 through 05/05/25 MAR and physician orders identified the following: The following PRN medications for pain lacked resident-specific parameters to direct unlicensed staff, including sequential order of use: * Acetaminophen 325 mg tab tablet (for pain/fever); and * Hydrocodone-APAP 5-325 mg tablet (for pain). Between 04/01/25 and 04 /18/25, the resident was administered acetaminophen on four occasions. The need to ensure MARs were accurate, including providing resident-specific parameters for PRN medications and medication notes, was reviewed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 04/2025 with diagnoses including dementia. Review of the resident's 04/01/25 through 05/05/25 MARs, 04/02/25 through 05/03/25 progress notes and physician communications and 4/08/25 signed physician orders showed the following: * Acetaminophen 325 mg tablets, take two tablets every six hours PRN (for pain); * Acetaminophen 500 mg tablet, take one tablet three times a day PRN (for pain); and * Morphine 20 mg/ml, take 0.5 ml every hour PRN (for pain). There were no resident specific parameters to direct unlicensed staff which medication to give first and in what order the other medications were to be administered. The need to ensure medication administration records were complete and included resident specific parameters for PRN use was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. The staff acknowledged the findings.

1. For residents 1 and 2. A full MAR review will be done and all resident specific parameters will be added 2. During the third check system, ED to review all orders after second checks are done to ensure MAR is accuratley being updated and followed. 3. Every day during third check system and every 90 days when renewals come back from PCP. 4. ED to ensure all orders are accuratley put into the system once they go to third checks.

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 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure PRN medications used to treat a resident's behavior had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering a PRN psychoactive medication, for 3 of 3 sampled residents (#s 1, 2 and 5) who were prescribed PRN medications to address behaviors. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 04/2025 with diagnoses including dementia. Review of the resident's 04/01/25 through 05/05/25 MARs, 04/02/25 through 05/03/25 progress notes and 4/08/25 signed physician orders showed the resident had the following order: * Lorazepam 1.0 mg tablet, give one tablet every four hours PRN for anxiety. The instructions for staff indicated the resident had anxiety with transfers. However, the resident was bed bound and no longer transferred out of the bed. There were no other resident-specific instructions for staff on what the resident’s anxiety looked like or what they should be watching for. The lorazepam PRN dose was not administered between 04/01/25 and 05/05/25. The need to ensure resident-specific information on how the resident expressed anxiety/agitation was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. The staff acknowledged the findings. 2. Resident 5 was admitted to the facility in 03/2025 with diagnoses including dementia. Review of the resident's 04/01/25 through 05/05/25 MARs, 03/12/25 through 05/01/25 progress notes and 03/11/25 signed physician orders showed the following: * Lorazepam 0.5 mg tablet, give one tablet twice daily PRN every four hours for anxiety. The medication was given three times between 04/01/25 and 05/05/25. The MAR lacked resident-specific information for staff on how the resident’s anxiety was expressed and what the staff should watch for. Additionally, there were no resident-specific interventions for staff to attempt prior to administration of the medication. The need to ensure resident-specific information on how the resident expressed anxiety/agitation and that non-drug interventions were attempted and documented prior to administration of the medication was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. The staff acknowledged the findings. 3. Resident 1 moved into the facility in 10/2021 with diagnoses including vascular dementia and generalized anxiety disorder. The resident had orders for lorazepam 0.5 mg tablet for generalized anxiety disorder – take ½ tablet by mouth once daily as needed. The facility failed to ensure there were specific parameters for staff describing how Resident 1 expressed anxiety. The need to ensure there were resident-specific descriptions for all PRN psychotropic medications was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. They acknowledged the findings.

1. Review all MAR'S for resdients 1,2 and 5 for any physotrophic medications and make sure they have parameters, if not then contact the RN to get parameters wanted. 2.New weekly MAR/NARC audit to be completed by RCC and given to the ED weekly. 3- Weekly. By the RCC and then the ED to review. 4- RCC responsible for completing weekly MAR/NARC audit, and ED responsible for ensuring it gets completed.

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by:

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by: Based on observation, interview and record review it was determined the facility failed to ensure devices with restraining qualities were assessed by an RN, OT or PT to determine safety of the device, the risks and benefits for the resident and if the least restrictive option was utilized for 1 of 1 sampled resident (#2). Findings include, but are not limited to: Resident 2 was admitted to the facility in 04/2025 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's care plan dated 04/01/25 showed the resident had two half side rails on his/her bed. The resident was observed to use the rails to help roll and partially hold his/her position during care. The resident was able to express minimal information regarding the device. The resident’s cognition was impaired, and s/he required full assistance from staff for all ADL care including feeding of meals and two-person assistance for bed mobility, incontinent care and dressing. Review of the resident's record showed no documented assessment or evaluation of the side rails. The resident’s care plan did not provide information to staff related to either device, safety/maintenance items to watch for or how to use the device with the resident. The need for a PT, RN or OT to complete an assessment of any device with restraining qualities and to include all required documentation was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. The staff acknowledged the findings.

1.Resdient 2 has had an assesment done by an RN regarding his bed rails. AS well as his service plan will be updated with this information 2. Hiring a fulltime RN who will be onsite 40 hours a week. 3- Any time there is a new order for any devices, restraining qualities, or any changes to baseline. 4- ED to ensure it gets sent to RN right away.

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 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 that 3 of 3 newly hired direct care staff (#s 7, 9 and 10) demonstrated competency in the use of abdominal thrust and first aid within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 05/06/25. There was no documented evidence that Staff 7 (MT), hired 02/24/25, Staff 9 (MT/CG), hired 03/03/25, and Staff 10 (CG), hired 02/15/25, had completed competencies in first aid and abdominal thrust. On 05/07/25 Staff 6 (Business Office Manager) confirmed the lack of documentation of first aid and abdominal thrust training for Staff 7, Staff 9 and Staff 10. The need to ensure direct care staff had demonstrated competency in first aid and abdominal thrust within 30 days of hire was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. They acknowledged the findings.

Full Audit of Staff 7, 9, 10 Files done and all documents not finished will be completed by those staff members. 2- New Hire Checklist Filled out and completed and Reviewed by the ED before the new hire touches the floor. 3- Every 90 days staff files will be reviewed for Expiry dates and before New hires hit the floor. 4- BOM to ensure its completed and handed to the ED before they start.

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 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with the Oregon Fire Code on alternate months. Findings include, but are not limited to: Fire and life safety records between 12/2024 and 05/2025 were reviewed and showed: a. Two fire drills were documented as completed in the last six months. b. Fire drills were not conducted on alternating months with fire life safety training. c. Drills were not conducted on alternating shifts to include all three shifts. d. Fire drill documentation was missing the following components: * Location of simulated fire; * Escape route used; * Evacuation time period needed; * Number of occupants evacuated; and * Evidence alternate routes were used. The need to ensure all required components were addressed and documented for each fire drill and that drills were conducted on alternating months from life safety training was discussed with Staff 1 (ED) and Staff 4 (Maintenance Director) on 05/05/25 and 05/06/25. The staff acknowledged the findings.

1. ED to make a fire drill monthly Schedule for the Mainteance Director to utilize. Ensuring fire drills and fire instructions are done on alternate months to be done monthly. 2. Monthly Schedule and Check Off sheets will be kept in a fire and life saefty Binder in the ED office to ensure compantacny and completion. 3- Monthly with all staff. 4- Maintenance Director and ED review

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

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents were instructed in fire and life safety procedures within 24 hours of admission and at least annually. Findings include, but are not limited to: Fire and life safety records were reviewed and discussed with Staff 1 (ED) and Staff 4 (Maintenance Director) on 05/05/25. There was no documented evidence residents were educated in general fire and life safety procedures, evacuation methods, responsibilities and designated meeting places inside or outside the building in the event of an actual fire within 24 hours of admission and again at least annually. The need to ensure fire and life safety instruction was provided to each resident within 24 hours of admission and again annually was discussed with Staff 1 and Staff 4. The staff acknowledged the findings.

1. Maintenance Director to Re do every residents Fire and life Safety Training. Then going forward to utilize the Department Checklist completion for new move ins mentioned in above POC. 2. ED to review once all residents have completed the training, and to review new move in checklist for completion 24 hours after move in. 3- Annually after initial move in training. 4- Maintenance Director then ED to Review the completion.

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 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF 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) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF 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 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure courtyard surfaces and surrounding pathways were maintained in good repair. Findings include, but are not limited to: Observations of fac ility pathways and patio areas on 05/05/25 identified the following: * Multiple drop-offs of 2 to 3 inches were noted in the courtyard, along pathways and outside exterior doorways; and * Cracked, lifting and/or broken sidewalk pieces were noted in the courtyard. The need to ensure pathways around the facility were in good repair with no potential tripping hazards were shown to and discussed with Staff 1 (ED) and Staff 4 (Maintenance Director) on 05/05/25 and 05/06/25. The staff acknowledged the findings.

1.Fill all the pathways side edges with more Dirt and then add a nice rock ontop of it. To prevent the rain from washing away the dirt.Walkthrough daily to make sure nothing is up against the fences. 2- Hopefully with the new dirt and rocks along the pathway, the rain will not wash it away and it will hold up. Walk through Daily before standup to make sure nothing is against the walls/fences. 3. Maintenance Director will inspect quartley to make sure all pathways and walkwasy are good and clear. 4- Maintenance Director to review and then ED to follow up.

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF 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) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF 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 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF 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 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (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 the 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. A RCF 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 will 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 the environment was maintained clean and in good repair. Findings include, but are not limited to: Observations of the facility between 05/05/25 and 05/07/25 showed the following areas in need of cleaning or repair: * Common area bathrooms were found to have missing and/or discolored sealant at the shower edge and the flooring. Several laminate boards were pulling apart at the seams creating gaps in the flooring. Transition strips at the doorways of the bathrooms were pulling away from floor edges and/or had pieces missing; * Lights throughout the hallways, television room and dining room had debris and/or dead bugs in the covers; *Round hanging lights in the entryway and dining room had dust accumulation and/or were discolored; * Wall chips and missing plaster were noted behind the nurse’s station; * A large crack between the outside door in the television room and wall was noted on the left-hand side; * Dining room blinds were covered with dust and debris. Windowsills had dirt, debris and dead insects present; * Flooring in the sunroom, television room, hallways and dining room had long scuffs, scratches and/or gouges. The television room and two short halls of the facility had chips, dings and large chunks of flooring missing. The transition areas at the doorways in the hallway were bubbled, raised and/or cracked; * The divider wall in Room 22 was scraped, dinged and had a loose chunk of board hanging down towards the floor; * Tables and chairs in the dining room, sunroom and television room had dings, scrapes, food spills and debris on arms, legs and/or fabric backs; * Two armchairs in the entryway had dark stains on the arms and lower portions of the chairs. A vinyl love seat in the entryway had worn fabric spots on the arms with an exposed fabric layer; * Two recliners in the tv room had stains and/or splatters, and one of the chairs had a large tear on the footrest with exposed foam; * A small, carpeted area in the television room was stained, frayed and missing large pieces of transition edge covering; and * The flooring in Room 8 and 9A had several sections that were pulling apart at the seams, creating gaps and/or small chips to the flooring. The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (ED) on 05/06/25. She acknowledged the findings.

1.Going room-room and inspecting all needs to be fixed. as well as all common area. Maintenance Director to gather the list and Review with ED to get all materials needed to get all fixed 2. Daily stand up with Managers will have a building walkthrough for each department to help maintain the building in general. And to note any thing that needs fixing after initial walkthrough of everything needing done. 3. Daily. 4. All Managers and ED follow up

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (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 the 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. A RCF 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 will be kept clean and in good repair. This Rule is not met as evidenced by:

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their units. Findings include, but are not limited to: During the survey from 05/05/25 through 05/07/25, observations and interviews with residents and staff confirmed not all residents had keys to their units. In interview on 05/05/25, Staff 1 (ED) indicated residents who wanted a key and could use a key were given one. They did not routinely give every resident a key to their units. The need to ensure all residents were provided keys to their units was discussed with Staff 1 on 05/05/25. She acknowledged the findings.

1. Lock smith quotes coming out to quote getting all new locks on every door, to get all new keys to be able to provide a key to every resdient. 2. Once all locks are changed there will be a set of keys for every resdient to have for their own door and a master key for caregivers and managers. 3. Whenever there is a lost key it will be replaced immediatley to provide to the resdient. 4. Maintenance Director and ED follow up.

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by:

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 231, C 372, C 420, C 422, C 510, and C 513.

all of the Following POC's attached to this Document to refer to C231 C372 C420 C422 C510 and C513. 2. All of the attached are being implemented by ED and followed through either weekly, quartley or daily to ensure compliance in all areas. 3.Depending on the POC it will be daily, quartley, or weekly. 4. ED to follow up with each POC and Department according to their correction plan.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by:

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. 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 staff (#s 7, 9, 10, and 18) completed all pre-service orientation requirements before performing any job duties, 3 of newly-hired direct care staff (#s 7, 9, and 10) completed pre-service training before independently providing personal care services and demonstrated competencies within 30 days of hire for all tasks assigned in the provision of resident services. Findings include, but are not limited to: Staff training records reviewed on 05/06/25 at 3:00 pm identified the following: 1. Staff 7 (MT), Staff 9 (CG), Staff 10 (MT/CG), and Staff 18 (Housekeeping), hired on 02/24/25, 02/15/25, 03/03/25 and 04/18/25, respectively, lacked documented evidence of completing pre-service orientation before performing any job duties as follows: a. Staff 7, 9, and 18 lacked abuse reporting requirements. b. Staff 10 completed fire safety and emergency procedures on 05/06/25. c. Staff 9 and 10 did not have signed job descriptions, and Staff 7 and Staff 18 signed their job descriptions on 05/06/25. d. Staff 9 lacked approved infectious disease prevention training, Home and Community Based Services (HCBS) training, and approved LGBTQIA2s+ training. 2. There was no documented evidence Staff 9 completed pre-service dementia training. 3. Staff 7, 9, and 10 lacked documented evidence of completing additional pre-service training prior to independently providing personal care as follows: a. Staff 7, 9 and 10 lacked: * Environmental factors that are important to a resident’s well-being (e.g. staff interactions, lighting, room, temperature, noise, etc.); * Family support and the role the family may have in the care of the resident; * How to recognize behaviors that indicate a change in the resident’s condition and report behaviors that require ongoing assessment; and * Use of supportive devices with restraining qualities in memory care communities. b. Staff 9 lacked how to provide personal care to a resident with dementia, including an orientation to the resident’s service plan. 4. Staff 7, Staff 9, and Staff 10 lacked documentation of demonstrated competency in any duty to which they were assigned. The need to ensure all required training was completed within the specified time frames was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. They acknowledged the findings.

1. Audit of staff 7,9,10 and 18's Files with New new hire checklist implemented. 2. As new hires come aboard they will be required to sign off on their checklists for training needs before stepping foot on the floor. as well as the ED to sign off before they hit the floor 3. With every new hire and Quartley for Expiration dates. 4. ED for New hires and Quartley and ED to Review to ensure it is completed before they start on the floor.

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by:

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 252, C 260, C 270, C 303, C 305, C 310, C 330 and C 340.

1. Attached POC's that refer to C252 C260 C27- C303 C305 C310 C330 and C340. 2. All new checklists and rules being implement for each of those tags to have more over sight by ED. 3. Dependent on each tag, either daily, weekly, quartley or as it arises. 4. ED to follow up on all POC plans.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by:

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in residents' care plans, for 2 of 3 sampled residents (#s 2 and 5). Findings include, but are not limited to: Residents 2 and 5's current care plans were reviewed during survey. Each of the care plans lacked information and staff instructions related to individualized nutrition and hydration status and needs. The need to develop individualized care plans addressing residents' nutrition and hydration was discussed with Staff 1 (ED) and Staff 2 (RCC). The staff acknowledged the findings.

1. All care Plans are being Evaluated by the ED and each Section is being re done. Each resdient will be asked individually what their likes and dislikes are. 2. ED to take over Care Plan Updates rather than the RCC doing it, as that was implemented before i got here. 3. Every quarter, Or Significant Change of Conditon, or change to any section of plan 4. ED to follow up with all Care plans as needed or Quartley.

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills. This Rule is not met as evidenced by:

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to develop an individualized activity plan based on an activity evaluation for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) whose activity plans were reviewed. Findings include, but are not limited to: Activity documents were reviewed with Staff 3 (Activities Director) on 05/06/25. Residents 1, 2, 3, 4, and 5 each had a “Then & Now” document and an “Individualized Activity Plans” document. The two documents together contained all the required components for an activity evaluation. There was no individualized activity plan developed for each resident based on their activity evaluation which detailed what, when, how and how often staff should offer and assist the residents with more individualized activities. The need to develop individualized activity plans which were based on the activity evaluation was discussed with Staff 3 on 05/06/25, and with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. They acknowledged the findings.

1. Each Individual Resident is getting a new Activities Assesment done by the life enrichment DIrector, and the ED is updating every single service plan to reflect their current likes or dislikes. 2. Every Quarter the life enrichment director will do a new assesment so the Ed can add it into the Care Plan updates. 3. Quartley 4. Life enrichment Director and ED.

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by:

OAR 411-057-0170(6) Secure Outdoor Recreation Area (6) SECURE OUTDOOR RECREATION AREA. The memory care community must comply with facility licensing requirements for outdoor recreation areas as well as the following standards. These requirements apply to newly endorsed, constructed, or remodeled communities which have construction documents approved on or after November 1, 2010 with the exception of subsections (d) and (e) of this section. (a) The space must be a minimum of 600 square feet or 15 square feet per resident, whichever is greater and is exclusive of normal walkways and landscaping. The space must have a minimum dimension of 15 feet in any direction; (b) Fences surrounding the perimeter of the outdoor recreation area must be no less than six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition; (c) Walkways must meet the accessibility requirements of the Oregon Structural Specialty Code. Walkway surfaces must be a medium to dark reflectance value to prevent glare from reflected sunlight; (d) Outdoor furniture must be sufficient weight, stability, design, and be maintained to prevent resident injury or aid in elopement; and (e) Doors to the outdoor recreation area may be locked during nighttime hours or during severe weather per facility policy. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure that fencing was no less than six feet in height, constructed to reduce the risk of elopement and that furniture was of sufficient weight to prevent injury or aid in elopement. Findings include, but are not limited to: A tour of the facility's MCC courtyard on 05/05/25 showed multiple sections of chain link fence in the courtyard and in two unsecured breezeways that were less than six feet in height. The shortest sections were approximately five feet four inches, up to five feet nine inches in height. The two unsecured breezeways had multiple plastic milk crates, chairs and/or cinder blocks stacked against or next to the chain link fences. These items posed an elopement risk as it gave residents items to stand on to aide in climbing the fence. The fencing sections that were less than six feet in height and the items stacked next to the fence were shown to and discussed with Staff 1 (ED) and Staff 4 (Maintenance Director) on 05/05/25. Staff 4 removed the stacked items. The staff acknowledged the findings.

1. The Fencing is getting Lattice atttached to the top of it, all fences and walls will be cleared of any objects that can be used to climb on, all lining of cement will be filled with dirt and rocks to prevent from washing away with the rain, all cement cracks will be filled and evened out. 2. Every week the Maintenance DIrector will do a walk through of the Exterior to ensure Compliance. 3. Every week 4- Maintenance Director and ED follow up.

OAR 411-057-0170(6) Secure Outdoor Recreation Area (6) SECURE OUTDOOR RECREATION AREA. The memory care community must comply with facility licensing requirements for outdoor recreation areas as well as the following standards. These requirements apply to newly endorsed, constructed, or remodeled communities which have construction documents approved on or after November 1, 2010 with the exception of subsections (d) and (e) of this section. (a) The space must be a minimum of 600 square feet or 15 square feet per resident, whichever is greater and is exclusive of normal walkways and landscaping. The space must have a minimum dimension of 15 feet in any direction; (b) Fences surrounding the perimeter of the outdoor recreation area must be no less than six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition; (c) Walkways must meet the accessibility requirements of the Oregon Structural Specialty Code. Walkway surfaces must be a medium to dark reflectance value to prevent glare from reflected sunlight; (d) Outdoor furniture must be sufficient weight, stability, design, and be maintained to prevent resident injury or aid in elopement; and (e) Doors to the outdoor recreation area may be locked during nighttime hours or during severe weather per facility policy. This Rule is not met as evidenced by: