OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 3) who was reviewed. Findings include, but are not limited to: Resident 3 moved into the community in 05/2025 with diagnoses including late onset Alzheimer's disease. The resident's move-in evaluation, dated 05/08/25, was reviewed. The following required elements had not been addressed: * List of medications and PRN use; * Pharmaceutical and non-pharmaceutical interventions related to pain; * History of dehydration or unexplained weight loss or gain; * Drug use; * Preferred pronouns; and * Gender identity. The need to ensure all move-in evaluation elements were addressed prior to the resident moving into the community was discussed with Staff 1 (Administrator) on 05/16/25 at 8:34 am. She acknowledged the findings.

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation 1) Resident # 3's move in evaluation was updated on 6/11/25 to reflect: List of medications and PRN use, Pharmaceutical and non-pharmaceutical interventions related to pain, History of dehydration, unexplained weight loss or gain, Drug use/abuse, Prefered Pronouns and Gender Identity. 2) The evaluation and move in evaluation will be updated to reflect:List of medications and PRN use, Pharmaceutical and non-pharmaceutical interventions related to pain, History of dehydration, unexplained weight loss or gain, Drug use/abuse, Prefered Pronouns and Gender Identity. The Administrator/Designee will be provided training on resident evaluations, completing all required components, and ensuring the evaluation is reflective of residents current needs. All resident evaluations will be reviewed and updated to ensure all required componets are completed and evaluation is reflective of residents current needs. 3) All new admissons will have a pre-admission and move in evaluation completed, as well as 30 day, quarterly or with change of condition. This will be monitored monthly with the use of the Administrator Quality Assurance audit. 4) The administrator/designee will be responsible to ensure the system has been corrected/monitored, with oversight from the Regional Director of Operations.

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs, provided clear direction to staff regarding the delivery of services, and were implemented for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 11/2024 with diagnoses including moderate vascular dementia with behavioral disturbance, osteoporosis, and anxiety. Observations were made of the resident's care from 05/15/25 through 05/16/25. Interviews with the resident and facility staff were conducted. The current service plan dated 05/08/25 was reviewed. Resident 1's service plan was not reflective of the resident's current needs, lacked clear instructions to staff, and/or was not implemented in the following areas: * Use of a pressure sensor while in bed; * Protein shakes including instructions on how often and what time staff were to provide them to the resident; * Use of a straw; and * Number of staff needed to assist with personal hygiene. The need to ensure the service plan reflected residents' current needs, provided clear instructions to staff regarding the delivery of services and was implemented was reviewed with Staff 1 (Administrator) on 05/16/25. She acknowledged the findings. 2. Resident 2 moved into the facility in 10/2023 with diagnoses including blindness of both eyes, history of transient ischemic attack, heart blockage, bradycardia, and hypertension. The current service plan, dated 04/25/25, and temporary service plans were reviewed, observations were made from 05/15/25 through 05/16/25, and interviews with the resident and facility staff were conducted. Resident 2's service plan was not reflective of the resident's current needs, lacked clear instruction to staff, and/or was not implemented, in the following areas: * Repositioning instruction that included daytime use of foam wedges in-between the resident’s legs and use of pillow to float feet; * Instruction related to the resident’s periodic hallucinations; * Current skin conditions; * Resident pronouns and gender identity; * Interventions used that included use of pool noodles on overlap table and yellow bell; * Bed bath instruction that included two person assist; * Incontinence care instruction that included two person assist; * Activity instruction related to one-on-one assistance; * Environmental factors including temperature, noise level of television, and to keep the door to his/her room open; * Left arm mobility and “tingly” left hand interventions and instruction to staff related to use of a red stress ball; * Meal assistance instruction that included time of meals, set-up required, assistive devices used, and resident preferences; * Hydration assistance instruction that included reminders and use of clear plastic cup with straw attached; and * Use of new hearing aids that included instruction and resident preferences. The need to ensure the service plan was reflective of the resident’s current needs, provided clear instruction to staff regarding the delivery of services, and was implemented was reviewed with Staff 1 (Administrator) on 05/16/25 at 10:06 am. She acknowledged the findings.

OAR 411-054-0036 (1-4) Service Plan: General 1) Resident #1's service plan was updated to reflect, pressure alarm, protein shakes, use of straw, number of staff to assist with personal hygiene, including clear instructions for staff regarding the delivery of services. Resident #2's service plan was updated to reflect repositioning, periodic hallucinations, current skin conditions, resident pronouns and gender identity, use of pool noodles, overlap table and yellow bell, bed bath and incontinence care with number of staff preforming services, activity instruction, environmental factors, meal assistace, hydration assistance, use of plastic cup/straw, use of new hearing aids with instructions and preferences, including clear instructions for staff regarding the delivery of services. 2)The Administrator/Designee will be provided training on resident service planning and all required components, including clear instruction for staff regarding the delivery of services. All resident service plans will be reviewed and updated to ensure all required componets are included, and the service plan is reflective of the residents current needs. 3) All resident service plans will be completed at move in, 30 day, quarterly and with change of condition to reflect the health status and provide clear instruction to staff. This will be monitored monthly with the Administrator Quality Assurance audit. 4) The administrator/designee will be responsible to ensure the system has been corrected/monitored, with oversight from the Regional Director of Operations.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to ensure changes of condition had actions or interventions determined, documented, and communicated to staff on each shift, and was monitored for effectiveness with weekly progress noted, through resolution, for 2 of 2 sampled residents (#s 1 and 2) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 10/2023 with diagnosis of blindness of both eyes, history of transient ischemic attack, heart blockage, bradycardia, and hypertension. Clinical records, including the current service plan, dated 05/25/25, observation notes, dated 02/17/25 through 05/10/25, and temporary service plans were reviewed and interviews with Resident 2 and facility staff were conducted. The following changes of condition were identified: * 04/17/25: “Dry raised areas on scalp and on skin”; and * 04/25/25: Unexpected family death. The above changes of condition lacked documented evidence actions or interventions were determined, communicated to staff on each shift, and were monitored through resolution. The need to ensure the facility communicated the determined resident-specific actions or interventions to staff following a short-term change of condition and documented weekly progress through resolution was reviewed with Staff 1 (Administrator) on 05/16/25 at 10:06 am. She acknowledged the findings. 2. Resident 1 was admitted to the facility in 11/2024 with diagnoses including moderate vascular dementia with behavioral disturbance, osteoporosis and anxiety. During the acuity interview on 05/15/25, the resident was identified as having experienced weight loss. Clinical records, including the current service plan, dated 05/08/25, observation notes dated 02/27/25 through 05/10/25, and weight records dated 11/08/24 through 05/15/25, were reviewed, and interviews with facility staff were conducted. The following changes of condition were identified: * 11/08/24: 138 pounds (admission); * 02/13/25: 144 pounds; * 03/13/25: 135 pounds; and * 05/15/25: 135 pounds (during the survey). From 02/13/25 to 03/13/25, Resident 1 had lost 9.0 pounds, which represented a change of condition. A review of the records showed the facility RN documented the following: * 03/10/25: A recommendation to provide increased assistance with meals while the resident was awake and to allow the resident periods of rest in between; * 03/13/25: The resident’s appetite had decreased and s/he experienced a weight loss compared to the previous week attributed to a significant decline in appetite over the past several days; * 03/17/25: Continue to provide high-calorie foods and snacks and assist with feeding as needed; * 03/30/25: Continue high calorie foods and protein shakes. Weekly weight monitoring was to continue; and * 04/08/25: The resident’s appetite continued to fluctuate. Staff to provide increased assistance and cueing during meals as needed and offering high-calorie foods and increasing the frequency of snacks between meals. There was no documented evidence the interventions for weight loss were communicated to staff for implementation. On 05/15/25 at 3:45 pm, Staff 4 (MA/CG) reported the resident was on a regular diet and not receiving a special or high-calorie diet. She continued to report that family provided protein heath shake last week, however, she was not sure of when or how often it should be administered. On 05/15/25 at 4:15 pm, Staff 1 (Administrator) confirmed that there was no temporary service plan or any other documented evidence in place to communicate the interventions to staff. During the survey, the resident was observed eating a meal in the dining room and was able to eat independently with staff providing verbal prompts to encourage intake. The resident appeared to have a good appetite; however, staff were not observed offering a protein health shake during the meal. A case of protein health shakes labeled with the resident’s name was observed in the pantry. The resident had no additional weight loss. The need to ensure resident-specific actions or interventions were clearly communicated to staff for implementation was discussed with Staff 1 on 05/15/25 at 4:15 pm. She acknowledged the findings.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring OAR 411-054-0040 Change of Condition 1. Resident #1: A tsp was implemented and service plan was updated to refect high calorie supplment 3 times a day at meals, increased calorie foods at meals and snack times, weekly weights to monitor for gain/loss. Resident #2's service plan was updated to reflect dry raised areas on scalp and skin, unexpected family death including instruction for delivery of care. 2. Administrator/designee and Community RN will be provided training regarding resident changes and the need for communication of changes to staff through a Temporary Service Plan.The Temporary Service Plan will have specific directions staff, including what the change is, what to monitor for, interventions put in place, signs and symptoms to report, who and when to report to. 3. The system will be reviewed daily to ensure compliance is maintained through review of daily reports, monitoring and 24 hour report. 4. The Administrator and/or designee and Registered Nurse will be respsonsible to ensure the corrections are completed and monitored, with oversight from the Regional Director of Operations. .

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on observation, interview, and record review, the facility failed to accurately capture care time and care elements that staff were providing to each resident as outlined in each individual service plan. Findings include, but are not limited to: The acuity interview on 05/15/25 revealed that there were no residents who required two staff members for transfers, no residents who had behaviors that negatively impacted them or other residents in the community that would need extra attention from staff, one resident had a private companion 12 hours a week, and one resident left the RCF to go to activities outside of the facility. The nine residents who resided in the RCF were observed during the survey. Residents were clean and dressed appropriately for the weather. The facility's environment was found to be clean and free of unpleasant odors. The facility's posted staffing plan was reflective of the following universal worker's hours: * Monday: Day shift - 12 hours, Evening shift - 14.5 hours, Night shift - 9.5 hours; * Tuesday: Day shift - 9 hours, Evening shift - 11.5, Night shift - 9.5 hours; * Wednesday: Day shift - 9 hours, Evening shift - 9.5 hours, Night shift - 9.5 hours; * Thursday: Day shift - 12 hours, Evening shift - 14.5 hours, Night shift - 9.5 hours; * Friday: Day shift - 13 hours, Evening shift - 15 hours, Night shift - 9.5 hours; * Saturday: Day shift - 13 hours, Evening shift - 15 hours, Night shift - 9.5 hours; and * Sunday: Day shift - 10 hours, Evening shift - 9.5 hours, Night shift - 9.5 hours. The facility's timecard information was reviewed and was reflective of the following actual hours of universal workers per shift: * Monday: Day shift - 8.5 hours, Evening shift - 9 hours, Night shift - 9 hours; * Tuesday: Day shift - 8.5 hours, Evening shift - 10, Night shift - 9 hours; * Wednesday: Day shift - 14 hours, Evening shift - 11.5 hours, Night shift - 9 hours; * Thursday: Day shift - 10.5 hours, Evening shift - 13 hours, Night shift - 9 hours; * Friday: Day shift - 4 hours, Evening shift - 13 hours, Night shift - 9 hours; * Saturday: Day shift - 4 hours, Evening shift - 13 hours, Night shift - 9 hours; and * Sunday: Day shift - no universal worker scheduled, Evening shift - 9 hours, Night shift - 9 hours. The facility's Acuity Based Staffing Tool (ABST) was reviewed and reflected the following minutes needed for the residents' scheduled and unscheduled needs: * Day shift: Between 20.35 and 18.10, which equated 2.71 to 2.41 staff members needed (or three universal workers); * Evening shift: Between 14.93 and 14.60, which equated 1.99 to 1.94 staff members needed (or two and a half universal workers); and * Night shift: Between 3.87 and 3.45, which equated 0.51 to 0.46 staff members needed (or one universal worker). On 05/16/25 at 8:34 am, Staff 1 (Administrator) confirmed that one staff member was off of the schedule for a planned surgery and that another staff member was also off as she was caring for her. Staff 1 didn't have enough employees to cover all shifts with both of those workers gone, so was picking up the shifts from 6:00 am to around 4:00 pm Thursday through Sunday. The sampled residents ABST minutes were reviewed as compared to their service plans. Three of three sampled residents' minutes were higher than their actual needs. On 05/16/25 at 8:34 am, Staff 1 continued to explain how she determined minutes for each resident and stated, "I look at the resident like we are caring for them on their worst day." When asked how often the nine residents experienced "their worst day," she stated only really with a "significant changes of condition." The need to ensure the facility accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan was discussed with Staff 1 on 05/16/25 at 8:34 am. She acknowledged the findings.

OAR 411-054-0037 (1)(b-g) Acutity Based Staffing Tool-ABST Time 1. The ABST tool will be adjusted/updated by the administrator for all residents. 2.The administrator/designee will be provided training on putting in average times, not worst times using the ABST provider guide and residents current and reflective service plan. 3.The system will be monitored prior to move in, and within the first 30 days, quarterly with service plan update, and with signifigant change of condition, using the move in audit tool as well as Monthly Administrator Quality Assurance Audit. 4) The administrator/designee will be responsible to ensure the system has been corrected/monitored, with oversight from the Regional Director of Operations.

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by: Based on observation and interview, the facility failed to provide a call system that connected resident units to the care staff and failed to provide a manually operated emergency call system in the bathrooms and bathing facilities used by residents and visitors. Findings include, but are not limited to: The facility was toured on 05/15/25 at 11:42 am. The following was identified: * Room one had a call system installed in the unit, but it was not in working order; * Room nine did not have call system installed in the unit; * Room four and seven's bathroom call system was in disrepair; and * The common use bathroom and shower room did not have a manually operated emergency call system. On 05/15/25 at 12:38 pm, room nine and the common use bathroom was provided a handheld bell to summon staff assistance if needed until the system was fixed. The need to ensure the facility had a working call system in resident units, resident bathrooms, and the bathroom and bathing facility used by residents and visitors was discussed with Staff 1 (Administrator) on 05/16/25 at 8:34 am. She acknowledged the findings.

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable 1) A new call system was ordered at time of survey. 2)Maintenance installed a new call system on 5/26/25. The system includes a working call system/unit in each residents apartment and bathroom as well as each common area bathroom. 3) The system will be evaluated daily to ensure all call system units are in place. 4) The Administrator/designee and Maintenance Director to ensure the corrections are completed/monitored with Regional Director of Operations oversight.

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (c) Each resident record must, before move-in and when updated, include the following information: (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (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. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure Pronouns and Gender identity were evaluated prior to or upon move-in. Findings include, but are not limited to: Refer to C252.

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident move-in & Evaluation: Res Evaluation Refer to C252