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 complete quarterly evaluations for 7 of 7 sampled residents (#s 1, 2, 3, 4, 5, 6 and 7) whose records were reviewed. Findings include, but are not limited to: Resident 1, 2, 3, 4, 5, 6 and 7’s records were reviewed during the survey and identified the following: There was no documented evidence that quarterly evaluations were completed for Residents 1, 2, 3, 4, 5, 6, and 7. In an interview on 06/04/25, Staff 1 (ED) acknowledged that quarterly evaluations had not been completed. On 06/04/25, the need to ensure evaluations were completed quarterly, as required, was discussed with Staff 1. He acknowledged the findings.

1. The actions that will be taken to correct the rule are: a) The residents quarterly evaluations for residents 1, 2, 3, 4, 5, 6, and 7 will be completed to accurately reflect the residents current needs and preferences. 2. The system will be corrected so that the violation will not occur by: a) The Licensed Nurse or designee will ensure that resident evaluations are are conducted at the time of move in, within 15-30 days of move in, with any change in condition, and quarterly to accurately reflect the residents needs and preferences. b) The Administrator or designee will maintain a monthly schedule of upcoming evaluations to ensure timely completion. 3. The area needing correction will be evaluated by the Licensed Nurse or Administrator by completing weekly audits to ensure compliance. Areas of non-compliance will be addressed immediately. 4. The Administrator and Licensed Nurse will be responsible to ensure that corrections are completed and monitored.

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

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs, provided clear directions to staff regarding the delivery of services, and/or were implemented for 7 of 7 sampled residents (#s 1, 2, 3, 4, 5, 6 and 7) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 05/2022 with diagnoses including dementia, traumatic brain injury, and hypotension (low blood pressure). During the survey, Resident 2 was observed to use a wheelchair with assistance for all mobility. Staff interviewed on 06/03/25 reported the resident was a full assist with transfers using a gait belt to the wheelchair. Staff reported the resident was not able to walk and was full assist of one person for all ADL cares to include meal assistance at times. Review of Resident 2’s service plans available for staff, dated 09/03/24 and 05/13/25, interim service plans, interviews with staff and resident, and observations during the survey revealed the service plan was not reflective of current care needs, and/or did not provide clear instructions to staff in the following areas: * Ambulation/mobility status; * Communication deficits; * Fall history with interventions; and * Meal assistance. On 06/04/25, the need to ensure service plans were reflective of current resident care needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 3 (RCC) and Staff 10 (MT). They acknowledged the findings. 2. Resident 3 was admitted to the facility in 04/2025 with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, and hypertension. During survey, Resident 3 was observed to wear glasses and hearing aids. The resident and staff reported that s/he was independent with transfers and ambulation, used a walker independently and was independent with ADLs except bathing. Review of Resident 3’s service plans available for staff, dated 04/15/25 and 05/28/25, interim service plans, interviews with staff and resident, and observations during the survey revealed the service plan was not reflective of current care needs, and/or did not provide clear instructions to staff in the following areas: * Shower assist; * Hospice services; * Side rail use; * Tremors to upper extremities; * Specialized utensils and glass/cup/straw for meals; * Oxygen, to include direction for staff; * Eyeglasses; and * Hearing aids. On 06/04/25, the need to ensure service plans were reflective of current resident care needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 3 (RCC) and Staff 10 (MT). They acknowledged the findings. 3. Resident 4 was admitted to the facility in 12/2018 with diagnoses including dementia. Observations of the resident, interviews with staff and review of the service plan, dated 05/06/25, showed the service plan was not reflective of the resident's current care needs, was not consistently implemented and/or did not provide clear direction to staff in the following areas: * Evacuation assistance; * Behaviors, hallucinations and dementia; * Toileting, significant output, incontinent care and brief changes; * Dressing, transfers and mobility assistance; * Vision impairment, orientation to food on the plate, and cut up food items; * One-person vs. two-person assistance; * Fall risk and safety interventions; * Fluid intake and placement of fluids; and * Wheelchair, walker and electric scooter use. The need to ensure resident service plans were reflective of current care needs, were consistently implemented and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 3 (RCC) on 06/04/25. They acknowledged the findings. 4. Resident 5 was readmitted to the facility in 11/2022 with diagnoses including pain. Observations of the resident, interviews with staff and review of the service plan, dated 02/12/25, showed the service plan was not reflective of the resident's current care needs, was not consistently implemented and/or did not provide clear direction to staff in the following areas: * Evacuation assistance; * Wheelchair, walker and electric scooter use; * Transfers, standby assist, mobility/ambulation; * Escorting resident to meals and activities; * Toileting, incontinent care and brief changes; * Dental status; * Diabetes, hypo/hyperglycemia and insulin use; * Dressing assistance related to lower body and walking boot; The need to ensure resident service plans were reflective of current care needs, was consistently implemented and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 3 (RCC) on 06/04/25. They acknowledged the findings. 5. Resident 1 was admitted to the facility in 10/2022 with diagnoses including myocardial infarction (heart attack) and type 2 diabetes. The resident’s record including the current service plan and progress notes dated 03/04/25 through 06/02/25 were reviewed. Observations were made, and staff were interviewed. The following was identified: a. The service plan available at the time of the survey was dated 02/12/25 and had not been updated quarterly, as required. b. The service plan was not reflective and/or did not provide clear direction to staff in the following areas: * Symptoms of high and low blood sugar; * Home health services and responsibilities; * Current skin condition and treatment; * Family member providing wound care; * Use of wheelchair; * Use of four-wheel walker; * Staff to encourage the resident to ambulate after meals; and * Resident-specific needs during evacuation. On 06/04/25, the need to ensure resident service plans were reviewed quarterly, were reflective of resident needs and provided clear direction to staff was discussed with Staff 1 (ED). He acknowledged the findings. 6. A review of Resident 6 and 7's service plans, interim service plans and interviews with care staff identified the following: Resident 6 and 7’s most current service plans were dated 02/12/25. In an interview on 06/04/25, Staff 1 (ED) confirmed Resident 6 and 7’s service plans had not been reviewed quarterly as required. The need to ensure resident service plans were reviewed quarterly was discussed with Staff 1 on 06/04/25. He acknowledged the findings.

1. The actions that will be taken to correct the rule are: a) The Licensed Nurse and/or designee will complete a comprehensive review and update of the service plans for all seven residents identified in the survey to ensure current ADL needs are accurately reflected and interventions are clearly documented and implemented. 2. The system will be corrected so that the violation will not occur by: a) The Licensed Nurse or designee will conduct a full audit of all current residents service plans to identify any additional discrepancies or updates needed. This will ensure that all service plans accurately reflect the resident’s current care needs and that staff have clear direction for implementation. 3. The area needing correction will be evaluated by the Licensed Nurse and/or Administrator by completing weekly audits to ensure compliance. Any areas of non-compliance will be addressed immediately. 4. The Administrator and Licensed Nurse will be responsible to ensure that corrections are completed and monitored.

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of the resident’s care needs, and provided clear instructions to staff for 1 of 3 sampled residents (#10) whose service plan was reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 10 moved into the assisted living community in 03/2025 with diagnoses including hypertension, chronic pain, and history of falls. Review of the resident’s clinical record, including observations made during an interview with the resident, identified the service plan was not reflective of his/her care needs and failed to provide clear direction to staff in the following areas: * One-person transfer with a gait belt versus a stand pivot transfer with reminders to use grab bars; * Assistance to keep glasses clean versus independent with vision care; * Assistance with oral care and grooming versus independent; * One-person assistance with dressing versus independent; * One-person assistance with toileting versus independent; * Preference of where s/he liked to eat meals; * Refusals for bed making and laundry assistance; * Use of a walking boot; * Home exercise program to promote strength and gait; and * Fall interventions. The need to ensure the service plan was reflective of care needs and provided clear instructions to staff was reviewed with Staff 1 (ED) and Staff 15 (RN) on 10/01/25 at 1:32 pm. They acknowledged the findings.

1. The actions that will be taken to correct the rule are: Resident 10's service plan will be updated to reflect his/her care needs and clear direction to staff. 2. The system will be corrected so that the violation will not occur by: All resident service plans have been reviewed and updated to accurately reflect the services being provided by staff. The Resident Care Coordinator has been re-educated on timely updates to the service plans to be reflective of care needs. 3. The area needing correction will be evaluated by the administrator and licensed nurse by reviewing a sample of 5 service plans monthly for accuracy and any discrepancies will be corrected immediately. 4. The Administrator and Licensed nurse will be responsible that corrections are completed and monitored.

OAR 411-054-0036 (5) Service Plan: Service Planning Team (5) SERVICE PLANNING TEAM. The service plan must be developed by a Service Planning Team that consists of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident. Involved family members and case managers must be notified in advance of the service-planning meeting.(a) As applicable, the Service Planning Team must also include:(A) Local APD or AAA case managers and family invited by the resident, as available.(B) A licensed nurse if the resident shall need, or is receiving nursing services or experiences a significant change of condition as required in 411-054-0045(1)(f)(D) (Resident Health Services).(C) The resident's physician or other health practitioner.(b) Each resident must actively participate in the development of the service plan to the extent of the resident's ability and willingness to do so. If resident participation is not possible, documentation must reflect the facility's attempts to determine the resident's preferences. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the residents choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 7 of 7 sampled residents (#s 1, 2, 3, 4, 5, 6 and 7) whose records were reviewed. Findings include, but are not limited to: Resident 1, 2, 3, 4, 5, 6 and 7's most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans. During interview on 06/03/25 with Staff 3 (RCC), she reported no documented or organized Service Planning Team was completed when service plans were updated. The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (ED) on 06/04/25. He acknowledged the findings.

1. The actions that will be taken to correct the rule are: a) The service plans for residents 1, 2, 3, 4, 5, 6, and 7 will be updated to reflect evidence as applicable that a service planning team participated in the development of the service plans. 2. The system will be corrected so that the violation will not occur by: a) The Licensed Nurse or designee will review all current residents evaluations and conduct service plans reviews including all applicable parties such as: Resident, Resident Legal Representative, any person of Resident's choice, Administrator, Licensed Nurse, and at least one other person who is familiar with the resident such as dietary team, and Life Enrichment team 3. The area needing correction will be evaluated by the Licensed Nurse and the Administrator by completing weekly audits to ensure compliance. Areas of non compliance will be addressed immediately. 4. The Administrator and Licensed Nurse will be responsible to ensure that corrections are completed and monitored.

OAR 411-054-0036 (5) Service Plan: Service Planning Team (5) SERVICE PLANNING TEAM. The service plan must be developed by a Service Planning Team that consists of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident. Involved family members and case managers must be notified in advance of the service-planning meeting.(a) As applicable, the Service Planning Team must also include:(A) Local APD or AAA case managers and family invited by the resident, as available.(B) A licensed nurse if the resident shall need, or is receiving nursing services or experiences a significant change of condition as required in 411-054-0045(1)(f)(D) (Resident Health Services).(C) The resident's physician or other health practitioner.(b) Each resident must actively participate in the development of the service plan to the extent of the resident's ability and willingness to do so. If resident participation is not possible, documentation must reflect the facility's attempts to determine the resident's preferences. This Rule is not met as evidenced by:

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had short term changes of condition were evaluated, resident-specific instructions or interventions were developed, the condition was monitored at least weekly to resolution and that interventions were re-evaluated to determine effectiveness for 3 of 5 sampled residents (#s 1, 2 and 5) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 11/2022 with diagnoses including pain. The resident's 02/12/25 service plan, 03/03/25 through 06/01/25 progress notes, incident investigation notes and physician communications were reviewed. The resident experienced multiple short-term changes without noted progress at least weekly until resolved, and/or lacked resident-specific directions to staff in the following areas: * Foot swelling; * Toe bruising and pain; and * Skin Tear. The need to ensure short-term changes of condition had documentation of weekly progress until resolution and provided resident-specific directions to staff was discussed with Staff 1 (ED) and Staff 3 (RCC) on 06/04/25. The staff acknowledged the findings. 2. Resident 2 was admitted to the facility in 05/2022 with diagnoses including dementia, traumatic brain injury and hypotension (low blood pressure). The resident's service plans, progress notes and incident reports dated 03/02/25 through 06/02/25, and MARs dated 05/01/25 to 05/31/25 were reviewed, observations were made, and interviews with staff were conducted. The following short-term changes of condition, documented in the progress notes, lacked actions or interventions determined and communicated to staff on all shifts, and were not monitored at least weekly to resolution: * 04/17/25 – Medication changes; * 04/18/25 – Fall; * 04/22/25 – New medication (Metamucil for constipation), and discontinuation of Melatonin (for sleep); * 04/29/25 – Fall with head strike; and * 05/13/25 – Fall. The need to ensure all changes of condition had actions or interventions determined and communicated to staff on all shifts, and/or were monitored at least weekly to resolution was discussed with Staff 1 (ED), Staff 3 (RCC) and Staff 10 (MT) on 06/04/25, and Staff 2 (RN) on 06/03/25. They acknowledged the findings. 3. Resident 1 was admitted to the facility in 10/2022 with diagnoses including myocardial infarction (heart attack) and type 2 diabetes. The resident's 03/04/25 through 06/02/25 progress notes, service plan dated 02/12/25 and interim service plans were reviewed, and interviews with staff and the resident were conducted. The following was identified: A progress note indicated Resident 1 had a chronic wound to his/her lower back. “Pinhole size draining wound.” There was no documented evidence the facility communicated actions or interventions to staff on each shift or monitored the condition at least weekly to resolution. The need to ensure actions or interventions for changes of condition were communicated to staff on each shift and the changes of condition were monitored through resolution was discussed with Staff 1 (ED) on 06/04/25. He acknowledged the findings.

1. The actions that will be taken to correct the rule are: a) The service plans for sample residents 1,2, and 5 will be updated to ensure that all short term changes of condition were documented and communicated to staff. The resident's progress will be evaluated at least weekly until resolution. 2. The system will be corrected so that the violation will not occur by: a) The Licensed Nurse or designee will review all current resident service plans to ensure service plans are descriptive of the residents current health and functional status. The Licensed Nurse or designee will ensure that all significant and short-term changes of condition are reflected in an updated service plan or temporary service plan respectively. The Licensed Nurse will document instructions and interventions that are specific to each change of condition. b) Any change will be monitored at least weekly with a minimum of a progress note and communicated to staff. 3. The area needing correction will be evaluated by the Licensed Nurse and the Administrator by completing weekly audits to ensure compliance. Areas of non compliance will be addressed immediately. 4. The Administrator and Licensed Nurse will be responsible to ensure that corrections are completed and monitored.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by:

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed to include documented findings, resident status, and interventions made as a result of the assessment for 1 of 3 sampled residents (# 2) who experienced a significant change of condition. Findings include, but are not limited to: Resident 2 was admitted to the facility in 05/2022 with diagnoses including dementia, traumatic brain injury and hypotension (low blood pressure). Observations of Resident 2 during survey revealed s/he used a wheelchair with assist for mobility and had word finding difficulties during conversation. On 06/03/25 during an interview, Witness 1 (Family member) reported that Resident 2 was no longer able to ambulate and had declined in her speech, cognition and mobility due to “a lot of falls with brain injuries”. Interviews with staff and review of the resident's 09/03/24 and 05/13/25 service plans, and 03/02/25 through 06/02/25 progress notes, and incident investigations were completed. The service plan indicated the resident used a walker for mobility with a gait belt and one staff assistance and was independent with meals after set-up. Staff 8 (CG) reported that Resident 2 had declined since a fall on 04/29/25, needing meal assistance at times, was more confused, and was unable to ambulate any longer due to knees buckling. The declines in mobility, cognition and ability to consistently eat and drink without assistance constituted a significant change of condition for Resident 2. Staff 2 (RN) and Staff 3 (RCC) reported on 06/03/25 there was no documented RN assessment completed for the significant change of condition. The need to ensure an RN assessment was completed for significant changes of condition which included findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (ED), Staff 3, and Staff 10 (MT) on 06/04/25. Staff acknowledged the findings.

1. The actions that will be taken to correct the rule are: a) The Licensed Nurse will complete a change of condition note/RN assessment for the change in condition on resident #2 2. The system will be corrected so that the violation will not occur by: a) The Licensed Nurse will complete the "Role of the RN" training course scheduled for August of 2025. 3. The area of correction will need to be monitored by the Licensed Nurse or designee and will conduct weekly audits of required clinical documentation and service plans of residents who experienced a change of condition. Areas of non compliance will be addressed immediately. 4. The Registered Nurse and The Administrator will be responsible for ensuring the corrections are completed and monitored.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by:

OAR 411-054-0050(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 ensure staff utilized proper infection control while serving in the dining room. Findings include, but are not limited to: Observations of the dining room during breakfast and lunch meal on 06/03/25 showed the following: * Four care staff were delivering meals and fluids to residents in the dining room. The staff were not wearing aprons or other clothing covers when serving food. * Staff were observed with gloves on. Multiple staff were touching other surfaces including the kitchen doors, wheelchair handles, and dirty dishes without a change of gloves. * Staff were exiting and entering the dining room without consistently changing gloves or washing hands. * Two staff were stopped and asked to change gloves and clean hands before beginning to serve in the dining room again. The need to ensure staff consistently used proper infection control, hand hygiene and glove use was discussed with Staff 1 (ED) and Staff 3 (RCC) on 06/04/25. The staff acknowledged the findings.

1. The actions that will be taken to correct the rule are: a) All staff involved in meal service on 06/03/25 were immediately re-educated on proper infection control protocols, including glove use, hand hygiene, and the requirement to wear aprons or clean clothing covers while serving food. b) all care and dietary staff will be provided aprons and will be required to wear aprons while serving food. 2. The system will be corrected so that the violation will not occur by: a) All direct care staff and dietary staff will be required to complete the "about infection control and prevention" training from Oregon Care Partners by 7/4/2025. b) Clear visual reminders (posters/signs) will be placed in the food service area to reinforce glove, apron and hand hygiene protocols. 3. The area needing correction will be evaluated by the Executive Chef or designee by observation at least 3 times per week. Observations will be documented and any areas of non compliance will be addressed on the spot. 4. The Administrator and Executive Chef will be responsible to ensure all corrections are completed and monitored.

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

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure staff documented non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications for 1 of 2 sampled residents (#7) who were prescribed and administered PRN medications to treat behaviors. Findings include, but are not limited to: Resident 7 was admitted to the facility in 07/2024 with diagnoses including anxiety disorder and obsessive-compulsive behavior. Resident 7 had a physician's order for lorazepam 0.5 mg as needed for anxiety. Resident 7's 05/01/25 – 05/31/25 MAR was reviewed. The resident was administered the psychotropic medication on 05/11/25, 05/13/25, 05/27/25, and 05/28/25 with no documented evidence staff had first attempted non-drug interventions with ineffective results. The need to attempt non-drug interventions prior to administering PRN psychotropic medications was reviewed with Staff 1 (ED) on 06/04/25. He acknowledged the findings.

1. The actions that will be taken to correct the rule are: a) The Licensed Nurse will update resident 7's record to accurately reflect non-drug interventions with effective/ineffective documentation. 2. The system will be corrected so that the violation will not occur by: a) The Administrator, Licensed Nurse, Resident Care Coordinator, and Med Techs will receive additional training by the community consultant on regulatory expectations regarding PRN psychotropic medication use, appropriate non-pharmacological interventions for behavior and anxiety, documentation standards and including when interventions are ineffective. b) The Licensed nurse will review all PRN psychotropic medication administrations weekly to ensure appropriate documentation of prior non-drug interventions. 3. The area needing correction will be evaluated by the Licensed Nurse or designee weekly and any areas of non compliance will be addressed immediately. 4. The Licensed Nurse and Administrator will be responsible to ensure all areas are completed and monitored.

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

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with restraining qualities was assessed by an RN, PT or OT prior to use, and instruction was provided to caregivers on precautions and correct use of the device, for 3 of 3 sampled residents (#s 2, 3, and 4) who had a supportive device with restraining qualities. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 05/2022 with diagnoses including dementia, traumatic brain injury, and hypotension (low blood pressure). During observation and interview, completed with Resident 2 and Witness 1 (Family member) on 06/03/25 it was reported and observed that the resident had a half side rail on his/her exiting side of the bed. On 06/03/25 Staff 8 (CG) reported the half side rail was put in the up position any time the resident was in bed to prevent him/her from getting out of the bed. There was no documented evidence the side rail had been assessed by an RN, PT or OT, or that caregivers had been instructed on precautions and the correct use of the device. On 06/04/25, the need to ensure an assessment was completed by an RN, PT, or OT prior to use of any supportive device with restraining qualities, including precautions and instructions to staff was discussed with Staff 1 (ED), Staff 3 (RCC), Staff 10 (MT), and on 06/03/25 with Staff 2 (RN). They acknowledged the findings. 2. Resident 3 was admitted to the facility in 04/2025 with diagnoses including congestive heart failure, chronic obstructive pulmonary disease and hypertension (high blood pressure). During an interview on 06/03/25 with Resident 3 it was observed that the resident had half side rails on each side of the bed. The right one was in the up position and the left side rail was down. There was no documented evidence the side rail had been assessed by an RN, PT or OT, or that caregivers had been instructed on precautions and the correct use of the device. On 06/04/25, the need to ensure an assessment was completed by an RN, PT, or OT prior to use of any supportive device with restraining qualities, including precautions and instructions to staff was discussed with Staff 1 (ED), Staff 3 (RCC), Staff 10 (MT), and on 06/03/25 with Staff 2 (RN). They acknowledged the findings. 3. Resident 4 was admitted to the facility in 12/2018 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the service plan dated 09/10/24 showed the resident had a half side rail on the left side of the bed. The rail was in the center of the bed. The service plan did not reflect a side rail was in use. The resident rarely got up out of bed. S/he was able to direct his/her own care and indicated the side rail helped him/her in bed. Review of the resident's record showed no assessment, or evaluation was completed of the device. The device was not evaluated at least quarterly to determine safety and appropriateness for the resident. The need to complete an assessment and the required components for the use of devices with restraining qualities was discussed with Staff 1 (ED) and Staff 3 (RCC) on 06/04/25. The staff acknowledged the findings.

1. The actions that will be taken to correct the rule are: a) The Licensed Nurse will be assessing residents 1, 2, and 4 including evaluation of medical necessity, risks, and resident preferences. 2. The system will be corrected so that the violation will not occur by: a) The Licensed Nurse or designee will complete a facility-wide audit of all residents using or potentially needing assistive devices to ensure complete assessments and proper documentation. 3. The area needing correction will be evaluated by the Resident Care Coordinator monthly to ensure all assistive devices assessments are completed, documented and care plans accurately reflect device use. 4. The Administrator will be responsible to ensure that all areas are completed and monitored.

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by:

OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff (6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF. (a) Annual infectious disease training requires the following: (A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training. (B) Annual in-service training must be documented in the employee record. (b) Biennial LGBTQIA2S+ training requires the following: (A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff. (i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite. (ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. (vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state. (D) The proposal for training submitted by a facility, entity, or individual shall include: (i) The regulatory criteria described in paragraph (C) of this section as part of the proposal. (ii) The following elements must be included in the proposal: (I) A statement of the qualifications and training experience of the facility, individual or entity providing the training; (II) The proposed methodology for providing the training either online or in person. (III) An outline of the training. (IV) Copies of the materials to be used in the training. (iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision. (c) Annual Home and Community-Based Services (HCBS) training requires the following: (A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations. (B) Annual in-service training must be documented in the employee record. (C) These annual trainings will be required as of April 1, 2025. (7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF. (a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire. (b) Requirements for annual in-service dementia training: (A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care. (B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter. (C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above. (D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia. (E) The facility shall determine the competency of direct care staff in dementia care in the following ways: (i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19). (ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff. (iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency. (8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 4 long-term direct care staff (#s 12, 13 and 14) completed 12 hours of annual in-service training, including at least six hours of dementia care based on their anniversary date of hire. Findings include, but are not limited to: Staff training records were reviewed on 06/03/25 and the following was identified: There was no documented evidence Staff 12 (MT), Staff 13 (MT), and Staff 14 (CG), hired 01/30/2018, 10/29/2020, and 08/24/2021 respectively, completed at least 12 hours of training based on their anniversary date of hire related to the provision of care in CBC, including a minimum of six hours of training on dementia care topics. The need to ensure and document that long-term direct care staff completed the required number of hours of annual in-service training was discussed with Staff 1 (ED) on 06/04/25. He acknowledged the findings.

1. The actions that will be taken to correct the rule are: a) The facility will complete an audit to bring all remaining staff up to compliance. 2. The system will be corrected so that the violation will not occur by: a) A tracking system will be created to ensure and monitor annual training compliance. 3. The area needing correction will be evaluated by the Administrator, Business Office Director or designee to ensure compliance quarterly to ensure all direct care staff remain in compliance. 4. The Administrator will be responsible to ensure that all areas are completed and monitored.

OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff (6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF. (a) Annual infectious disease training requires the following: (A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training. (B) Annual in-service training must be documented in the employee record. (b) Biennial LGBTQIA2S+ training requires the following: (A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff. (i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite. (ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. (vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state. (D) The proposal for training submitted by a facility, entity, or individual shall include: (i) The regulatory criteria described in paragraph (C) of this section as part of the proposal. (ii) The following elements must be included in the proposal: (I) A statement of the qualifications and training experience of the facility, individual or entity providing the training; (II) The proposed methodology for providing the training either online or in person. (III) An outline of the training. (IV) Copies of the materials to be used in the training. (iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision. (c) Annual Home and Community-Based Services (HCBS) training requires the following: (A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations. (B) Annual in-service training must be documented in the employee record. (C) These annual trainings will be required as of April 1, 2025. (7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF. (a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire. (b) Requirements for annual in-service dementia training: (A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care. (B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter. (C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above. (D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia. (E) The facility shall determine the competency of direct care staff in dementia care in the following ways: (i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19). (ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff. (iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency. (8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process. This Rule is not met as evidenced by:

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to Oregon Fire Code and fire and life safety instruction to staff was provided on alternate months. Findings include but are not limited to: Fire drill records for 01/01/2025 through 06/02/2025 were reviewed on 06/02/25, and revealed the following: a. Fire drills lacked documentation of one or more of the following components: * The escape route used; * Evacuation time-period needed; and * Evidence alternate routes were used during fire drills. In an interview on 06/03/25, Staff 1 (ED) acknowledged the documentation lacked one or more of the required components. b. The facility failed to provide fire and life safety instruction to staff on alternate months. In an interview on 06/03/25, Staff 1 confirmed staff were not provided fire and life safety instruction. The need to ensure fire drills were conducted according to Oregon Fire Code with all required components documented and fire and life safety instruction to staff was provided on alternating months was discussed with Staff 1 on 06/04/25. He acknowledged these findings.

1. The actions that will be taken to correct the rule are: a) The facility will be conducting fire drills moving forward to include complete documentation of the specific escape route used, the total evacuation time, verification that alternate routes are rotated and used as part of drill scenarios. b) The facility will create a fire and life safety instruction schedule to ensure education is provided to staff at minimum on alternating months throughout the calendar year. 2. The system will be corrected so that the violation will not occur by: a) The administrator or designee will review all fire logs within 48 hours to ensure all required elements are included. b) A tracking system will be created to ensure and monitor training compliance. 3. The area needing correction will be evaluated by the Administrator, Business Office Director or designee to ensure compliance quarterly to ensure all direct care staff remain in compliance. 4. The Administrator will be responsible to ensure that all areas are completed and monitored.

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

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents were provided fire and life safety training within 24 hours of admission and annually according to the Oregon Fire Code (OFC). Findings include, but are not limited to: Facility Fire and Life Safety records from 01/01/2025 to 06/02/2025 were reviewed on 06/03/25. The following was identified: * The facility fire and life safety records lacked documented evidence residents were provided training and instruction on fire and life safety within 24 hours of admission to the facility; and * There was no documented evidence the residents were re-instructed on fire and life safety procedures at least annually. The need to ensure residents were instructed on fire and life safety procedures within 24 hours of admission to the facility and re-instructed at least annually was discussed with Staff 1 (ED) and Staff 4 (Environmental Service Director) on 06/04/25. They both acknowledged the findings.

1. The actions that will be taken to correct the rule are: a) The facility will audit all current residents records to include documentation of fire and life safety training. Any areas of non compliance will be addressed immediately by providing the required instruction. 2. The system will be corrected so that the violation will not occur by the administrator or designee will schedule annual re-instruction tied during the month of admission or done community-wide. 3. The area needing correction will need to be monitored quarterly through service plan meetings. 4. The Maintenace Director and The Administrator will be responsible for ensuring all areas are completed and monitored.

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

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C260, C610, and C613.

See POC for all Citations

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory care communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure courtyard surfaces and surrounding pathways were maintained in good repair. Findings include, but are not limited to: Observations of facility pathways and patio areas on 06/02/25 and 06/03/25 identified the following: * Multiple drop-offs of 2-5 inches were noted in the along pathways around the perimeter of the facility and outside exterior doorways; and * Cracked, lifting and/or broken sidewalk pieces near the patio areas and the exterior pathways at the back of the facility. The need to ensure pathways around the facility were in good repair with no potential tripping hazards were shown to and discussed with Staff 1 (ED) and Staff 4 (Environmental Services Director) on 06/03/25. The staff acknowledged the findings.

1. The actions that will be taken to correct the rule are: a) The facility will be filling and leveling drop offs to return to immediate compliance. b) The facility has marked with a yellow visible spray any areas of uneven surface to inform staff, residents, and visitors until permanent repair is completed. 2. The system will be corrected so that the violation will not occur by: a) The community will conduct monthly perimiter walks to identify any areas of non compliance. Any areas of non compliance will be addressed immediately. 3. The area needing correction will be evaluated by the Administrator and Maintenance Director weekly through weekly perimeter walks. 4. The Administrator and Maintenance Director will be responsible for ensuring all areas are completed and monitored.

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory care communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure courtyard surfaces and surrounding pathways were smooth and maintained in good repair. This is a repeat citation. Findings include, but are not limited to: Observations of facility pathways and patio areas on 09/30/25 through 10/01/25 identified the following: * Multiple areas of concrete were lifting up approximately one to three inches and were uneven in the patio areas and along the exterior pathways at the back of the facility and around the perimeter of the building. Observations during the survey identified the patio and walking path were used by several residents. The need to ensure exterior pathways around the facility were smooth and in good repair, with no potential tripping hazards, was discussed with Staff 1 (ED) on 09/30/25 at 3:52 pm. He acknowledged the findings.

1. The actions that will be taken to correct the rule are: The facility had concrete replacement scheduled for 10/21/2025 to ensure all areas are smooth and in good repair. 2. The system will be corrected so that the violation will not occur by: The Administrator and Maintenance Director will walk the community perimiter once a week to ensure the community is in good repair with no potential triping hazards. 3. The area needing correction will be evaluated by the Administrator and the Maintenance Director weekly and address any areas of non compliance immediately. 4. The Administrator and Maintenance Director will be responsible that corrections are completed and monitored.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. Findings include, but are not limited to: Observations of the facility between 06/02/25 and 06/03/25 showed the following areas in need of cleaning or repair: * Laundry rooms on both floors had scrapes to the walls, spills, stains and chips to the interior and exterior cabinet doors and drawers. Linoleum flooring was ripped, dinged and/or had large pieces missing between the washers and dryers. The first-floor laundry room had two windowsills with chipped paint and surfaces were spongy and soft to the touch; * Furniture in seating areas of the upstairs hallway had spills and splatters on the arms, seats and/or the outer surfaces; * Four light fixtures in the dining room had debris inside the fixtures; * Room 213 had numerous spills, stains to kitchenette shelves, cupboards and drawers. Shelves had large dark stains with chipped and/or missing pieces of paint, and a large piece of counter laminate was pulled away. Bathroom flooring was cracked and had dark brown stains around the base of the toilet, red splatters to the wall and brown substance on the floor of the shower; * Room 226 had spills and stains on the kitchenette counter tops and inside cupboards. The bathroom floor was cracked, and brown stains and debris were near the base of the toilet; * Second floor common bathroom had a large crack in the wall, laminate floorboards were pulling apart at the edges, creating gaps that allowed dirt and debris to accumulate; * Windowsills throughout the dining room and hallways had dirt, debris, dead insects and/or dust. Multiple blinds located in the dining room were dusty with dark stains; * Activity room kitchen had multiple spills, stains and debris to both the interiors and exteriors of the cupboards and drawers. Large yellow spills/stains were noted in the upper cupboards and two drawers. Clean dish items were stored in both areas. Spills and splatters were noted on the floor; a counter mixer was covered with white substance on the bowl and the upper mixer. Large dark stains and debris were noted in the cabinet under the sink and thick white accumulation was noted to be stuck to the drawer fronts near the sink. A long untreated/unsealed wood shelf had multiple food and non-food items stored on it; and * Vents along the lower part of the wall in the hallways, on both floors, had substantial dust accumulation. The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (ED) and Staff 4 (Environmental Services Director) on 06/02/25 and 06/03/25. The staff acknowledged the findings.

1. The actions that will be taken to correct the rule are: a) All stained, dirty furniture was cleaned. b) High traffic areas including laundry rooms, dining room fixtures, hallway vents, activity room were deep cleaned and sanitized. c) Rooms 213, 226 will be scheduled for repair work including bathroom repair and counter/cabinet touch ups. d) Second floor common bathroom wall was scheduled for repair. 2. The system will be corrected so that the violation will not occur by: a) All housekeeping staff will be trained on infection control and sanitation protocols, routine and deep-cleaning procedures, proper documentation and reporting of deficiencies. 3. The area needing correction will be evaluated by the Administrator and Maintenance Director through weekly and monthly community walks. Any areas of non-compliance will be addressed immediately. 4. The Administrator and Maintenance Director will be responsible for ensuring all areas are completed and monitored.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure the interior environment was maintained clean and in good repair. This is a repeat citation. Findings include, but are not limited to: Observations of the facility between 09/30/25 and 10/01/25 showed the following areas were in need of cleaning or repair: a. Laundry room on the first floor- * Multiple areas had gouges in the drywall and areas of wall were damaged behind the washing machines; * Spills, stains, and chipped shelving to the interior of the cabinet below the sink; * Linoleum flooring was torn between the washers and dryers, rendering the surface uncleanable; * The windowsills had been exposed to water which caused the paint to peel and the surfaces were spongy and soft to the touch; and * A dryer had a broken knob and was not functioning properly. b. Second floor laundry room- * There were multiple holes in the wall approximately six inches in circular shape behind the dryers; * Approximately one inch by two foot cut in the drywall to the right of the dryers; * The wall behind the washing machines had multiple areas of water damage causing the paint to bubble and peel in some areas; * The linoleum floor covering was torn in multiple areas between the washer and dryers; * A folding table had four broken corners that exposed sharp edges; and * The dryer labeled “4” was not operational. c. Bathrooms - * The bathroom floor in room 226 was cracked and had brown stains and debris near the base of the toilet; and * The second-floor common bathroom had a large crack in the wall. The areas in need of cleaning and/or repair were discussed with Staff 1 (ED) on 10/01/25 at 10:38 am. He acknowledged the findings.

1. The actions that will be taken to correct the rule are: a) Laundry Room areas will be repaired and maintained. b) Second Floor Laundry Room areas will be repaired and maintained. c) Bathroom floor in room 226 will be scheduled for repair. Second Floor bathroom crack on the wall will be repaired and maintained. 2. The system will be corrected so that the violation will not occur by: a/b) The Maintenance Director and the Administrator will complete once a week interior audits to identify any areas in need of correction and complete immediatley. c)The resident care coordinator or designee will complete a 3 room audit weekly to ensure all items are clean and in good repair. 3. The area needing correction will be evaluated by the Administrator and Maintenance Director through weekly and monthly community walks. Any areas of non-compliance will be addressed immediately. 4. The Administrator and Maintenance Director will be responsible for ensuring all areas are completed and monitored.

OAR 411-054-0300 (11-13) Call System (11) CALL SYSTEM. An ALF 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 at each resident bathroom, central bathing rooms, and public-use restrooms.(b) EXIT DOOR ALARMS. Exit door alarms or other acceptable systems must be provided for security purposes and to alert staff when residents exit the ALF. 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.(a) RESIDENT PHONES. Each unit must have at least one telephone jack to allow for individual phone service.(b) PUBLIC TELEPHONE. There must be an accessible local access public telephone in a private area that allows a resident or another individual to conduct a private conversation.(13) TELEVISION ANTENNA OR CABLE SYSTEM. An ALF 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, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to: Observations on 06/02/25 and 06/03/25 showed exit doors to the resident patio and at the end of hallways, did not have an operational alarm or other acceptable system to alert staff when residents exited the building. The need to ensure exit doors were equipped with a functional alarming device or other acceptable system was discussed with Staff 1 (ED) on 06/03/25. He acknowledged the findings.

1. The actions that will be taken to correct the rule are: a) The facility will be placing an audible alarm to exit doors leading to the outdoor areas of the facility. 2. The system will be corrected so that the violation will not occur by: a) All direct care staff will be re-educated on what to do when an exit door alarm malfunctions. b) The Maintenance Director will perform weekly inspections of all exit doors to verify functionality. 3. The area needing correction will be evaluated by the Maintenance Director or designee weekly through weekly community walks. 4. The Administrator and Maintenance Director will be responsible for ensuring all areas are completed and monitored.

OAR 411-054-0300 (11-13) Call System (11) CALL SYSTEM. An ALF 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 at each resident bathroom, central bathing rooms, and public-use restrooms.(b) EXIT DOOR ALARMS. Exit door alarms or other acceptable systems must be provided for security purposes and to alert staff when residents exit the ALF. 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.(a) RESIDENT PHONES. Each unit must have at least one telephone jack to allow for individual phone service.(b) PUBLIC TELEPHONE. There must be an accessible local access public telephone in a private area that allows a resident or another individual to conduct a private conversation.(13) TELEVISION ANTENNA OR CABLE SYSTEM. An ALF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by:

OAR411-004-0020(1)(d) Individual Rights Settings Right to Freedom (1) Residential and non-residential HCB settings must have all of the following qualities: (d) The setting ensures the individual the right to freedom from restraints, except in accordance with the standards set forth in ORS 443.739, OAR chapters 309 and 411, 1915(c) HCBS Waivers, 1915(i) State Plan HCBS, or 1915(k) Community First Choice (K State Plan Option). When the right to freedom from restraints must be limited due to a threat to the health and safety of an individual or others, an individually-based limitation as described in OAR 411-004-0040 must apply in any residential or non-residential setting. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the individual the right to freedom from restraints for 1 of 1 sampled Resident (#2) who had a side rail restraint device. Refer to C340.

Refer to C340 for Plan of Correction

OAR411-004-0020(1)(d) Individual Rights Settings Right to Freedom (1) Residential and non-residential HCB settings must have all of the following qualities: (d) The setting ensures the individual the right to freedom from restraints, except in accordance with the standards set forth in ORS 443.739, OAR chapters 309 and 411, 1915(c) HCBS Waivers, 1915(i) State Plan HCBS, or 1915(k) Community First Choice (K State Plan Option). When the right to freedom from restraints must be limited due to a threat to the health and safety of an individual or others, an individually-based limitation as described in OAR 411-004-0040 must apply in any residential or non-residential setting. This Rule is not met as evidenced by: