OAR 411-054-0025 (5) Facility Administration: Required Postings (5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following: (a) Facility license. (b) The name of the administrator or designee in charge. The designee in charge must be posted by shift or whenever the administrator is out of the facility. (c) The current facility staffing plan. (d) A copy of the most recent re-licensure survey, including all revisits and plans of correction as applicable. (e) The Ombudsman Notification Poster. (f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections. (g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted. (h) Other notices relevant to residents or visitors required by state or federal law. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure required postings were in a routinely accessible and conspicuous location to residents and visitors. Findings include, but are not limited to: The Residential Care Facility (RCF) was toured on 05/13/25. The following were not posted as required: * Resident Rights and Protections, as described in OAR 411-054-0027, including the LGBTQIA2S+ Rights and Protections; and * The LGBTQIA2S+ Nondiscrimination Notice. In a 05/14/25 interview, Staff 2 (Administrator) reported she was unaware the resident rights including the LGBTQIA2S+ rights and protections postings, and the LGBTQIA2S+ Nondiscrimination Notice were required. The need to ensure all required items were posted was reviewed with Staff 2 and Staff 3 (RCC) on 05/15/25 at 2:15 pm. They acknowledged the findings.

1. Poster for non-discrimination Notice for LGBTQIA2S+ was posted. 2. Administrator Alerts will be read, whenever new or updated required postings are listing, it will be printed out to ensure that compliance is met. 3. If new Administator Alerts are emailed regarding this subject matter. 4. The administrator is responsible to see that it is being monitored.

OAR 411-054-0025 (5) Facility Administration: Required Postings (5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following: (a) Facility license. (b) The name of the administrator or designee in charge. The designee in charge must be posted by shift or whenever the administrator is out of the facility. (c) The current facility staffing plan. (d) A copy of the most recent re-licensure survey, including all revisits and plans of correction as applicable. (e) The Ombudsman Notification Poster. (f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections. (g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted. (h) Other notices relevant to residents or visitors required by state or federal law. This Rule is not met as evidenced by:

OAR 411-054-0025 (9) Facility Administration: Quality Improvement (9) QUALITY IMPROVEMENT PROGRAM. The facility must develop and conduct an ongoing quality improvement program that evaluates services, resident outcomes, and resident satisfaction. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to conduct an ongoing quality improvement plan that evaluated resident services, staff performance, resident outcomes, and resident satisfaction. Findings included, but are not limited to: During the re-licensure survey, conducted 05/12/25 through 05/15/25, the quality improvement plan to ensure adequate resident care, services, and satisfaction was found to be ineffective. At 12:45 pm on 05/15/25, Staff 2 (Administrator) was interviewed and confirmed the facility had a quality improvement program, which included reviewing results from the Residential Care Quality Metrics Program, however the plan had not yet been implemented. The need to ensure the facility conducted an ongoing quality improvement program that evaluated services, resident outcome and satisfaction was discussed with Staff 2 and Staff 3 (RCC) on 05/15/25. No additional information was provided. Refer to the deficiencies in the report.

1. Facility will conduct annual audit of quality metrics focusing on resident evalutions of services, staff performances, and resident satisfaction (through third party survey). 2. Facility staff will select specific dates in advance and block them out to ensure time and accuracy for review of QAPI. 3. Qualitty metrics will be gathetered quarterly and and annually, audited, and analyzed. 4.Administrator, RCC, FRN, Med Tech, Direct Care Staff, Kitchen, and Life Enrichment.

OAR 411-054-0025 (9) Facility Administration: Quality Improvement (9) QUALITY IMPROVEMENT PROGRAM. The facility must develop and conduct an ongoing quality improvement program that evaluates services, resident outcomes, and resident satisfaction. This Rule is not met as evidenced by:

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure residents’ rights to receive services in a manner that protected privacy and dignity for 2 of 3 sampled residents (#s 1 and 2) who received ADL assistance, and to have medical records kept confidential for multiple unsampled residents. Findings include, but are not limited to: a. Resident 1 was admitted to the facility in 06/2023 with diagnoses including type 2 diabetes mellitus, chronic suprapubic catheter, pressure ulcer, and severe obesity due to excess calories. During the acuity interview on 05/12/25, Resident 1 was identified as receiving wound care daily from facility staff and home health nurse due to chronic ulcer wounds. During the survey from 05/12/25 through 05/15/25, the surveyor obtained permission and observed the facility staff providing personal care and wound care to Resident 1. Resident 1 was noted to require total care assist from the staff. On 05/13/25 at 10:11 am, Resident 1 was observed laying on a hospital bed on his/her right side facing the wall bare from the waist down. The hospital bed was positioned perpendicular to, and in view of, the window, and the window blinds were open. Staff 15 (CG) was in the resident’s room and stated Staff 9 (Facility RN) was coming to perform wound care. While Staff 9 performed wound care from 10:18 am to approximately 10:41 am, the window blinds remained open. The window of another resident’s room was about six feet away from Resident 1’s window and facing Resident 1’s room. b. Resident 2 moved into the community in 04/2025 with diagnoses including orthostatic hypotension (drop in blood pressure after standing up). During the acuity interview on 05/12/25, Resident 2 was identified to require ADL assistance. During an ADL observation with Resident 2 and Staff 15 (CG) at 10:55 am on 05/15/25, blinds to a sliding glass door were not closed during toileting tasks. The sliding glass door led to an exterior walkway used by residents. The resident’s bathroom was visible from the walkway, potentially exposing the resident to residents or staff walking outside the sliding door. c. Observations of meal service and feeding assistance were made between 05/12/25 and 05/15/25. Multiple staff members were observed standing over residents instead of sitting next to them while providing feeding assistance. d. During an interview with Staff 8 (MT) on 05/14/25 at 10:29 am, a text thread shared between MTs, Staff 2 (Administrator), Staff 3 (RCC), and Staff 9 (Facility RN) was viewed. This thread contained information about multiple residents, using room numbers, initials, and last names as identifiers. A photograph of a resident who had fallen was also viewed. An interview with Staff 2 on 05/14/25 at 1:19 pm confirmed the use of text messages on staff personal phones to transmit resident information. The need to create an environment in which residents received services in a manner that protected privacy and dignity and that medical records were kept confidential was reviewed with Staff 2 and Staff 3 on 05/15/25 at 11:35 am. They acknowledged the findings.

1. a) & b) Facility held shift meetings as well as facility wide meetings to remind staff to close all blinds and sliding door blinds while doing care. 1. c) Facility held shift meetings as well as facility wide meeings to remind staff that when assisting a resident with meal assist, to sit with them at eye level. 1. d) HIPPA approved texting app was set up and implemented. Facility is using Tigerconnect for its communication needs 2.a) & b)Reminders during staff meetings, and walk through the building. c) Remind and observe during mealtimes to be at eye level with the resident that they are providng meal assistance with. d)Will also remind and provide continuing education with Tigerconnect. 3. a) & b) Daily reminders if needed for closing the blinds and sliding door blinds. c) Daily reminders if needed during mealtimes. d) Daily teachings if needed, on contract for two years with Tigerconnect, will renew. 4. Administrator and RCC will be responsible to see that corrections are monitored and completed

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by:

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the main facility kitchen and common area kitchenette on 05/12/24, from 9:42 am through 1:00 pm, revealed the following deficient practices: a. An accumulation of food spills, splatters, loose food and debris, dirt, dust, black matter, and grease was visible on or underneath the following: * Pipes/tubing behind warewasher; * Blade of can opener; * Interior of cabinet under prep area sink; * Fan blades of stand-up fan blowing on the three-compartment sink area; * Interior of microwave on 2nd floor kitchenette; * Exterior of stove top on 2nd floor kitchenette; * Sides of industrial equipment, including fryer and rack under the grill top; and * Multiple cabinets storing clean dishes, pots, pans, and glassware. b. The following items were in need of repair: * Cabinets and drawers with chipped/peeling wood around the hardware knobs; * Wall behind the warewasher and to the left of the three-compartment sink had scrapes, gouges, and other damage; and * Can opener was dull, with metal shavings observed. c. Sanitizer buckets with cleaning cloths were tested using test strips and were shown to have a lower concentration of sanitizing chemical than the acceptable range on the test strip instructions. d. Kitchen staff were observed to handle a ready-to-eat food item with potentially contaminated gloves during meal serve out. e. Kitchen staff did not check the temperature of fish cakes, cilantro rice, and mixed vegetables before plating and serving to residents. f. Multiple pans, pots, and cutting boards were noted to be heavily worn, stained, and/or scratched. g. Multiple food items found in cold food storage were not dated when opened. h. Cooking utensils were stored below the air conditioner window unit with cooking surfaces exposed to potential contamination. i. The handwashing sink, directly next to where clean trays were being stored to dry, lacked a splash guard to prevent potential contamination. j. A staff member was observed to potentially contaminate hands and food items after s/he left the kitchen via an exit door to the outside. S/he returned approximately two minutes later through the same door with a container of butter. S/he opened the butter container, dated it, and resumed stirring the vegetables over the stove. S/he failed to complete hand hygiene upon returning to the kitchen. k. Multiple observations were made of the kitchen staff not properly performing hand hygiene prior to performing a clean task. On multiple occasions, Staff 16 (Chef) was observed using the kitchen's prep sink to wash their hands. There was no soap used or available at the sink. S/he then rinsed his/her hands for less than ten seconds and dried their hands using a soiled towel. l. Staff 1 (Owner) was not able to correctly demonstrate adequate knowledge for cook-to temperatures, correct order of cold food storage, reheat temperatures, proper cooling procedures, and signs and symptoms of foodborne illnesses. m. The second-floor kitchenette, where both facility and residents stored food, was toured with Staff 1 and the following was identified in the two stand-up refrigerator/freezers: * A resident’s ice pack, stored in a trash bag, was underneath the facility’s unopened, frozen bag of sausage patties; * Multiple items in the freezers and refrigerators were not dated or labeled when opened or prepared; and * Black food debris was found on the shelf in the fridge on the right side. Areas of concern were shown to and discussed with Staff 2 (Administrator) and Staff 1 on 05/12/25 at 1:30 pm. They acknowledged the identified areas needing to be cleaned and repaired, improper storage of food in fridge and freezers, improper sanitizing, lack of proper hand hygiene between dirty and clean tasks and prior to handling ready-to-eat foods.

1 a) All kitchen items were either removed if deemed not in usable condition, other items listed were cleaned and santized. b) Cabinet doors and drawers will be sanded down and revarnished. New can opener was purchased. Wall behind the ware washer and to the left of the three compartment sink has been repaired. c) Chemicals and test strips were purchased for sanitizer bucket. d) Staff trained on infection protocol. e) Kitchen staff trained on safe food handling. f) All kitchen pots, pan and cutting boards that were deemed not in good condition were replaced. g) Staff trained on proper dating protocol. h) Cooking utensils were placed in different area of the kitchen. i) Splash guard was installed. j) Staff educated on infection protocol and food safety handling. k) Staff educated on infection protocol and food safety handling. l) Staff educated on infection protocol and food safety handling. m) Fridge and freezer cleaned and food items properly dated when opened. 2. a) A regular cleaning schedule will be implemented. b) Cabinet doors and drawers will be monitored frequently to referred to maintianence on an as needed basis. c) Chemicals have been added and on cycle to be delivered to the facility. Test strips will be used every 2 hours to ensure that it is at the right level. d),g), j), k), l) & e) Will hold routine inservices for all staff regarding infection control and food handling. f) Kitchen to monitor and request new equipment as needed. h) Cooking utensils permanetly removed from that area. i) Splash guard installed and will be monitored for replacement as needed. m) Kitchen staff to check resident food items to ensure they have an open date and food items are not expired. As well as fridge and freezer are cleaned regularly. 3. a) Cleaning schedule daily and weekly. b) Annually and as needed. c) Chemicals and test strips are scheduled to be delivered monthly. Test strips for sanitation bucket to be tested every 2 hours and changed. d), g), j), e), k) & l) Will hold monthly inservices for infection protocol and food safety handling. f) Kitchen staff to replace equipment as needed. h) As needed to ensure nothing is placed there. i) As needed if new splash guard needs to be placed or fixed. m) Kitchen staff to check resident food items that are opened twice weekly to ensure that all opened items have open dates and aren't expired. Kitchen staff will also clean fridge and freezer based on cleaning schedule. 4. Administrator, chef, and kitchen aides

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). 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 resident move-in evaluations addressed all required elements for 1 of 1 sampled resident (#2) whose move-in evaluation was reviewed. Findings include, but are not limited to: Resident 2 moved into the facility in 04/2025 with diagnoses including spinal fractures and orthostatic hypotension. The move-in evaluation failed to address the following elements: * Customary routines with bathing; * Cultural preferences and traditions; * Cognition, including memory and confusion; * Personality, including how a person copes with change or challenging situations; * Non-pharmaceutical interventions for pain; * Complex medication regimen; and * Recent losses. The need to ensure move-in evaluations included all required elements was reviewed with Staff 2 (Administrator) and Staff 3 (RCC) on 05/15/25 at 12:30 pm. They acknowledged the findings.

1. Move in evaluation was updated and the following were added: cutstomary routines with bathing, cultural preferences and traditions, cognition including memory and confusion, personality and how a person copes with change or challenging situations, non pharmaceutical interventions for pain, complex medication regimen and recent losses. 2. Facility forms were upated to include all of the missing information for intake. 3. Facility forms will be updated annually or as Administrator Alerts are sent updating required information for new admissions . 4. Administrator, RCC and FRN will be responsible for completing and monitoring

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 411-054-0040 (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 interview and record review, it was determined the facility failed to refer significant changes of condition to the facility nurse, to determine and document what actions or interventions were needed for short-term changes of condition, to communicate resident-specific instructions and interventions to staff on each shift, to monitor the change of condition at least weekly until resolved, and/or to monitor each resident consistent with his/her evaluated needs and service plan for 3 of 3 sampled residents (#s 1, 2, and 3) who experienced changes of condition; and the facility failed to have written policies to ensure a resident monitoring and reporting system was implemented 24-hours a day. Findings include, but are not limited to: 1. Resident 2 moved into the community in 04/2025 with diagnoses including orthostatic hypotension (low blood pressure when standing). The current service plan, dated 03/26/25, and progress notes, dated 04/06/25 through 05/07/25, were reviewed. Interviews with staff were completed between 05/12/25 and 05/15/25. a. The facility failed to determine actions or interventions needed for the resident, communicate the actions or interventions to staff on each shift, and/or document weekly progress until the condition resolved for the following short-term changes of condition: * 04/06/25: New move-in; * 04/06/25: Skin tear to right upper arm; * 04/11/25: Skin tear to left elbow; and * 04/24/25: Discontinuation of calcitonin nasal spray. b. On 05/14/25 at 1:14 pm, Staff 3 (RCC) was asked to provide a copy of the facility’s written policy to ensure a resident monitoring and reporting system was implemented 24-hours a day. Staff 3 reported the facility did not have written policies for monitoring and reporting. The need to ensure the facility determined and documented what action or interventions were needed for changes of condition, communicated the actions or interventions to staff on all shifts, monitored the short-term changes of condition at least weekly through resolution, and had a written policy to ensure a resident monitoring and reporting system was implemented was discussed with Staff 2 (Administrator) and Staff 3 on 05/15/25 at 12:30 pm. They acknowledged the findings, and Staff 2 confirmed the facility did not have policies regarding monitoring and reporting.2. Resident 3 was admitted to the facility in 10/2023 with diagnoses including Alzheimer's disease and chronic kidney disease. The resident’s clinical record was reviewed, observations were made, and staff were interviewed during the survey. a. The facility documented the following weight records for Resident 3: * 12/26/24: 156 pounds; * 01/09/25: 156.1 pounds; * 02/20/25: 157 pounds; * 03/20/25: 146 pounds; * 04/28/25: 146 pounds; and * 05/08/25: 146.2 pounds. Between 02/20/25 and 03/20/25 Resident 3 experienced weight loss of 11 pounds, or 7.00% of his/her total body weight, in one month. This constituted a severe weight loss and was a significant change of condition. On 04/24/25, the following was noted: “...5.5% weight loss over the last three months, currently [Resident 3] gets assist of 1:1 feeding and also uses Boost/Ensure supplement as well. Discussed weight loss recently with PCP at the last appointment on April 9th, will follow up again with PCP at next appointment on [05/14/25] about weight loss as it is fairly large weight loss but not significant. Moved resident to check weight twice weekly.” On 05/14/25 at 1:55 pm, Staff 3 (RCC) stated the resident was administered nutritional shakes daily and the weight monitoring system the facility used did not highlight the resident’s severe weight loss as of 03/20/25. The facility lacked documented evidence Resident 3 was referred to the facility RN regarding his/her 7.00% total body weight loss in one month. b. The resident was noted to have experienced the following short-term changes of condition: * 02/17/25: Blood and redness found in [perineal area]; * 03/20/25: Medication order change: decrease Metformin (for diabetes) from 1000 mg twice daily to 500 mg twice daily; * 04/22/25: Unwitnessed fall ; * 04/25/25: Unwitnessed fall; * 05/01/25: Unwitnessed fall; * 05/05/25: Missed medication: Hizentra 7 grams (for immune deficiency) via intravenous injection weekly; and * 05/12/25 : Missed medication: Hizentra 7 grams via intravenous injection weekly. The facility lacked documented evidence previously implemented fall interventions for Resident 3 were evaluated for effectiveness or determined if other interventions needed to be developed and each short-term change of condition had actions or interventions determined, documented, communicated to staff, and conditions were monitored with progress noted at least weekly. The need to ensure the facility referred significant changes of condition to the facility RN, determined, documented, and communicated the determined actions or interventions to staff, monitored residents per their evaluated needs and service plans, and monitored conditions, with documented progress at least weekly, until short-term changes of condition were resolved was reviewed with Staff 2 (Administrator) and Staff 3 on 05/15/25 at 2:56 pm. They acknowledged the findings. Resident 1 was admitted to the facility in 06/2023 with diagnoses including type 2 diabetes mellitus, chronic suprapubic catheter, pressure ulcer, and severe obesity due to excess calories. Resident 1's progress notes, dated 02/12/25 through 05/12/25, and service plan, dated 03/20/25, were reviewed. The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved: * 02/12/25: “…reduce levothyroxine to 250mcg daily.”; * 02/12/25: changes to insulin on sliding scale orders to control blood sugar level; * 02/18/25: “…this wound is basically chronic from sharing since [resident] is dependent to hoyer lift [sic].”; * 03/07/25: return to the facility after hospitalization related to acute hypoxemic respiratory failure and aspiration pneumonia from 03/01/25 through 03/07/25; * 03/10/25: “…O2 [oxygen] in certain positions 89% [outside of normal parameters] but up to 91-92% when repositioned.”; * 03/12/25: “Flushed suprapubic catheter….noticed reddish sediments in the tubing…”; * 03/20/25: started new order for supplemental oxygen as needed; * 03/20/25: change of suprapubic catheter; * 04/03/25: “Seen that some parts of the wounds were bleeding …and…a little foul odor observed [sic].”; * 04/05/25: “…a wound that is actively bleeding.”; * 04/07/25: change of suprapubic catheter; * 04/09/25: “When the bandage was removed, it [wound] was bleeding profusely.”; * 04/16/25: “ …res [resident] demanded the back scratcher to aid in itching [sic].”; * 05/02/25: return to the facility after hospitalization related to septic shock with suprapubic catheter associated with urinary tract infection from 04/24/25 through 05/02/25; * 05/02/25: change to pain management orders; * 05/06/25: discontinue oxybutynin (for overactive bladder); and * 05/11/25: “Resident has no BM [bowel movement] record for a couple of days now.” The need to ensure the facility had a system in place to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, to communicate the determined action or intervention to staff, and to document progress until the condition resolved was reviewed with Staff 2 (Administrator) and Staff 3 (RCC) on 05/15/25 at 11:35 am. They acknowledged the findings.

1. a) Facility has made written monitoring policies in place for short term change of condition. b) Facility has made written policies in place for monitoring and reporting 24 hours a day. c) Policy was made on when to have RN referrals. d) & e) Policy was made for interventions and monitoring for resident change of conditions and reporting to FRN for follow up assessments. 2. Facility has made and implented policies on changes of condition and monitoring. 3. Policies will be reviewed quarterly and additional monitoring will be done on an as needed basis with inclusion with the quality improvement program. 4. Administrator, RCC and FRN

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 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment for 1 of 3 sampled residents (#1) and multiple unsampled residents dependent on staff for care needs and meal service. The facility also failed to designate an individual to be the facility’s Infection Control Specialist. Findings include, but are not limited to: a. Observations of meal service were conducted on 05/12/25 through 05/14/25. Caregiving staff were observed serving food and feeding residents without wearing a protective barrier over potentially contaminated clothing. Multiple staff were observed handling food trays, touching their faces, coughing, touching residents and wheelchairs, and assisting residents with feeding tasks without performing hand hygiene between dirty and clean tasks. b. In an interview on 05/15/25, Staff 2 (Administrator) and Staff 3 (RCC) acknowledged the facility did not designate an individual to be the facility’s “Infection Control Specialist,” responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The need to ensure the facility maintained infection prevention and control protocols to provide a safe, sanitary, and comfortable environment during meal service, and designated an individual to be the facility’s “Infection Control Specialist,” was reviewed with Staff 2 and Staff 3 on 05/15/25 at 11:35 am and again at 12:30 pm. They acknowledged the findings.

1. a) Facility has purchases clothing barriers were purchases for staff to use with meal assistance and meal services. Staff educated on food safety handling and infection control protocol. b) Administrator has taken and completed infection control specialist class oon 5/29/25. 2. a) Staff are being monitored for wearing clothing barriers at all meal times, food safety and infection control protocol classes are being provided monthly. b) Infection control course will be retaken every 2 years, and is set to a timed notification. 3. a) daily monitoring for clothing barriers. a) & b) Food Safety and infection control protcols will be updated quarterly with infection control team. 4. Administrator, RCC, FRN, Chef, Supervisor/Direct Care Staff

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 1 of 3 sampled residents (# 3) whose orders were reviewed. Findings include, but are not limited to: Resident 3 was admitted to the facility in 10/2023 with diagnoses including Alzheimer's disease and chronic kidney disease. The resident's MARs, dated 04/01/25 through 05/12/25, and physician orders were reviewed, observations were made, and staff were interviewed. The following was noted: a. Resident 3 had an order for pureed to mechanical soft food textures with thin liquids and required full assistance with eating meals. Observations made on 05/14/25 at 9:13 am found the resident was served oatmeal, scrambled eggs, and two sausage links for breakfast. The sausage links were cut into bite sized pieces. The cut sausage links were considered regular texture and did not follow the resident’s prescribed diet. The resident was observed to eat the links without coughing or choking, and interviews with care staff confirmed resident did not have a history of coughing or choking on foods. In interviews with Staff 7 (CG) and Staff 16 (Cook) at 9:14 am and 9:22 am, respectively, they relayed they were unaware that cutting the sausage links into bite sized pieces did not meet Resident 3’s diet order for pureed to mechanically soft food textures. b. The resident had a physician’s order for Hizentra (for immune deficiency) 7 grams via intravenous injection weekly. According to the MAR, Resident 3 did not receive his/her weekly dose of Hizentra on 05/05/25 and 05/12/25 as prescribed. During an interview with Staff 3 (RCC) on 05/14/25 at 2:27 pm, he explained Resident 3 was not administered 7 grams of Hizentra on 05/05/25 or 05/12/25, as the medication was not available. The need to ensure physician orders were followed as prescribed was discussed with Staff 2 (Administrator) and Staff 3 on 05/15/25 at 12:45 pm. They acknowledged the findings.

1. a) Kitchen and Direct Care Staff educated on diet consistency, and textures. b) Provider will be notified of all missed medications. 2. a) Education will be regularly provided to staff on proper diet consistency. Resident diets will be cross-refrenced with kitchen quarterly and on COC with service plan team. b) Providers for all residents will be notified of missed/refused medications. Provider will inform community via intake form on notification consistency. 3. a) Staff will evaluete diets quarterly and based on COC and provide education as needed to staff and on the monthly inservices. b) When resident changes provider or is admitted to community intake form for medication refusal/missed doses will be sent to provider. 4) Administrator, Chef, Kitchen Aides, RCC, FRN

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 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to have a minimum of two direct care staff scheduled and available at all times whenever a resident required the assistance of two direct care staff for scheduled and unscheduled needs. Findings include, but are not limited to: The facility consisted of a single two-story building that housed 38 residents at the time of the survey. The current facility staffing plan and Acuity Based Staffing Tool (ABST) were reviewed, and interviews with facility staff were conducted. The following was revealed: * The first floor had five residents who required two-person assist and the use of a mechanical lift for transfers; * The second floor had six residents who required two-person assist and the use of a mechanical lift for transfers; * During the acuity interview, the facility stated there were five additional residents in the facility who used sit-to-stand devices and needed one- or two-person assist with transfers; and * According to the facility’s posted staffing plan, two direct care staff were scheduled to cover the night shift, leaving only one staff available to assist those who required two-person assist while the other staff was on break. During an interview with Staff 2 (Administrator) and Staff 3 (RCC) on 05/13/25 at 2:31 pm, both acknowledged the need to have additional direct care staff. On 05/13/25 at 3:52 pm, the survey team received an email from Staff 2 stating the staffing coverage for the night shift was increased to three direct care staff, and the facility staffing plan was updated accordingly. The need to have a minimum of two direct care staff scheduled and available at all times whenever a resident required the assistance of two direct care staff for scheduled and unscheduled needs was reviewed with Staff 2 and Staff 3 on 05/14/25 at 11:44 am. They acknowledged the findings.

1. Facility had added a second direct care staff to noc shift. 2. Facility will ensure that there are 3 staff members on shift during noc shift and will refer to ABST tool for staffing. 3. Whenever care needs are changed and referring to ABST tool to update how many staff members are needed at noc shift. 4. Administrator, RCC

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by:

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) was completed or updated and reviewed for each resident before the resident moved in and updated no less than quarterly for 2 of 2 sampled residents (#s 1 and 3) and multiple unsampled residents. Findings include, but are not limited to: During the acuity interview at 10:02 am on 05/12/25, Staff 2 (Administrator) and Staff 3 (RCC) confirmed the facility census was at 38 residents. The facility’s ABST data and posted staffing plan were reviewed at 1:58 pm on 05/12/25 and revealed the following: a. As of Monday, 05/12/25, 36 residents had been entered into the ABST to drive the caregiving time output. Resident 2 and two unsampled residents had no ABST data. b. Eight residents out of 36 were added to the ABST on 05/12/25. c. There was no documented evidence the ABST data for Residents 1 and 3 had been updated quarterly. The need to ensure residents’ ABST was updated no less than quarterly and/or upon move-in was discussed with Staff 1 and Staff 2 on 05/14/25 at 11:44 am. They acknowledged the findings.

1. Administrator will update the ABST quarterly when the service plan is due, before a resident moves in and as needed when change of condition. 2. Administrator will set a date quarterly and will block out time weekly to update ABST. Moving forward, the Administrator will update ABST upon changes to the resident and when service plan is due. 3. Quarterly. 4. Administrator

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by:

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 6, 7, and 8) demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 05/13/25 and revealed the following: There was no documented evidence Staff 6 (MT), Staff 7 (CG), and Staff 8 (MT), hired 03/20/23, 02/01/24, and 07/09/22, respectively, demonstrated competency in all assigned job duties within 30 days of hire in one or more of the following areas: * Providing assistance with ADLs; and * First aid/abdominal thrust. The need for staff to demonstrate competency in their assigned job duties within 30 days of hire was discussed with Staff 2 (Administrator) and Staff 3 (RCC) on 05/13/25 at 2:00 pm. They acknowledged the findings.

1. All new hired staff will ensure they have first aid and abdominal thrust within 30 days of hire. ADL's Competency for staff including Medication Techinicians to be completed within 30 days of hire. 2. Staff will be onboarded using checklist facility form ensuring all steps are completed. 3. Annual evaluation of system will be completed with staff performances. 4. Administrator, FRN, and RCC.

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 provide fire and life safety instruction to staff on alternating months and to document all required elements for fire drills in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to: On 05/13/25, fire and life safety records, dated 11/2024 through 04/2025, were reviewed and revealed the following: * Fire and life safety instruction was not consistently provided to staff on alternating months. * Fire drill records lacked documented evidence of the staff members on duty and participating. During an interview with Staff 2 (Administrator) on 05/13/25 at 11:57 am, she identified the designated point of safety as a building across the street from the facility. Staff interviews regarding the designated point of safety did not identify this location as the place to gather in the event of a fire. The need to ensure fire and life safety training was conducted on alternating months and all required components were documented was discussed with Staff 2 and Staff 3 (RCC) on 05/13/25. The staff acknowledged the findings.

1. a) FLS instructions will be done on alternating months b) Fire drills will be document with staff member names on duty. 2. a) New typed up policy and instructions have been made and handed out to all staff for FLS. b) New form made to include area to write down all the staff member names who are participating in the fire drills. 3. After every fire drill proccess will be evaluated for safety and effciency. 4. Adminstrator & Administrative Assistant

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 re-instruct residents on fire and life safety at least annually, with a written record of the content of the training sessions and the residents attending, per the Oregon Fire Code (OFC). Findings include, but are not limited to: Review of facility fire and life safety records on 05/13/25 identified the following deficiencies: * There was no documented evidence annual re-instruction on fire and life safety was provided to residents. In an interview on 05/13/25 at 1:14 pm, Staff 2 (Administrator) indicated the residents received re-instruction annually for fire and life safety “with someone from the fire department” but acknowledged there was no documented evidence of a written record of the content of the training sessions or the residents who attended. On 05/13/25 at 2:00 pm, the need to provide and document fire safety re-instruction to residents annually in accordance with the Oregon Fire Code was discussed with Staff 2 and Staff 3 (RCC). They acknowledged the findings.

1. Facility will set up annual FLS teachings from local fire department and document residents in attendance. 2. Life Enrichment will be setting up annual training and teaching from the local fire department. 3. Annually. 4. Life Enrichment.

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 the general exterior of the building was maintained in good repair. Findings include, but are not limited to: The exterior of the facility was toured on 05/13/25 and the following was identified: * Surfaces of wooden railings, handrails, stairs, and pathways of the exterior common use areas of the facility had chipped paint, scrapes, gouges, and holes which presented possible hazards for residents; and * Cement pathways of the exterior common use areas had a build-up of green debris, leaving the surfaces uneven and creating possible tripping hazards for residents. The exterior areas of the facility were toured with Staff 2 (Administrator) and Staff 3 (RCC) on 05/07/25 at 9:15 am. They acknowledged the findings.

1. a) Deck and railings in backyard will be replaced. b) Green debris buildup on concrete pathways has been pressure washed away. 2. Maintenance will perform quarterly and annual care to deck and pathways to ensure they are clean and safe. 3. Maintenance will perform quarterly walk throughs of exterior facility and handle additional repairs quarterly or as needed. 4. Facility Maintenance

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 all interior materials and surfaces were kept in good repair. Findings include, but are not limited to: The facility was toured on 05/13/25 and the following was identified: Multiple wooden tables in the common use areas of the facility were not in good repair, with scrapes, cracks, and gouges on the surfaces. During a facility tour on 05/14/25 at 2:45 pm, the need to ensure the interior of the facility was in good repair was discussed with Staff 2 (Administrator) and Staff 3 (RCC). They acknowledged these findings.

1. Wooden tables will be cleaned, sanded, and varnished. 2.Maintenance will perform quarterly and annual care to tables. 3. Maintenance will perform quarterly walk throughs of interior of facility and handle additional repairs quarterly or as needed. 4. Facility Maintenance

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 and interview, it was determined the facility failed to ensure sampled and unsampled residents who resided in the facility had a key to their units. Findings include, but are not limited to: In an interview on 05/14/25 at 12:15 pm, Staff 2 (Administrator) and Staff 3 (RCC) stated residents were offered a key upon move-in, but if the resident refused, it was documented in the service plan and a key was not issued. The need to ensure all residents had a key to access their unit was reviewed with Staff 2 and Staff 3 on 05/15/25 at 12:30 pm. They acknowledged the findings.

1. All residents were given a key to their room, if a resident refused it was hung up in their closet in their room for their access. 2.All residents moving in will be given a key at move in, if they do not want a key a copy can be given to POA by request, a copy of the key will be hung up in the room in their closet. 3. At move in/ all new admissions. 4. Administrator, Maintenance

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 411-054-0025 (5)(f)(g) Facility Administration: Required Postings (5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following: (f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections. (g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure LGBTQIA2S+ Rights and Protections and the LGBTQIA2S+ Nondiscrimination Notice were posted in a routinely accessible and conspicuous location to residents and visitors and were available for inspection . Findings include but are not limited to: Refer to C 152

1. Poster for non-discrimination Notice for LGBTQIA2S+ was posted. 2. Administrator Alerts will be read, whenever new or updated required postings are listing, it will be printed out to ensure that compliance is met. 3. If new Administator Alerts are emailed regarding this subject matter. 4. The administrator is responsible to see that it is being monitored.

OAR 411-054-0025 (5)(f)(g) Facility Administration: Required Postings (5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following: (f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections. (g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted. This Rule is not met as evidenced by: