OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to immediately notify the local Seniors and People with Disabilities (SPD) office of any incident of abuse, or suspected abuse, and include all required elements in their investigation for 1 of 1 sampled resident (#6) and one unsampled resident who had reportable incidents. Findings include, but are not limited to: Resident 6 moved into the facility in 03/2022 with diagnoses including heart attack. During an interview with the resident on 06/03/25 at 10:06 am, s/he reported an incident in which an unsampled resident made a rude gesture and proceeded to “hit” Resident 6 seven times on the upper back. Resident 6 reported feeling shoulder tenderness “for two weeks afterward.” On 06/04/25 at 10:45 am, a Community Complaint Form dated 01/26/25 was reviewed outlining the facility’s investigation of the incident. The investigation lacked the following required information: * Time and place and individuals present; * Response of staff at the time of the event; and * Follow-up action. In an interview on 06/04/25 at 11:50 am, Staff 1 (ED) confirmed the incident was not reported to the local SPD office. Survey requested the facility report the incident and confirmation was received prior to survey exit. The need to ensure the facility immediately notified the local SPD office of abuse, or suspected abuse, and included all required information in their investigations was reviewed with Staff 1, Staff 3 (Director of Health Services) and Staff 4 (Regional Nurse Consultant) on 06/04/25 at 1:00 pm. They acknowledged the findings.

Incident was reported prior to the conclusion of the survey visit. A review of incidents in the last 30 days was conducted to assure reporting had been conducted as required by current rules. Re-education provided to the applicable department heads on current reporting reqiurements and completion of the occurrence related documents. Resident incidents and supporting documentation will be routinely reviewed by ED and ALD for timely reporting. Daily during stand up ALD and ED

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

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:? 1. On 06/02/25 at 11:00 am, the kitchen was toured with Staff 9 (Cook). The following areas of concern were identified: * Pipes, walls, steam table knobs, gauges, disposal, drain, and flooring behind/underneath the dish machine and three compartment sinks had black matter, grease, and corrosion on them; * The caulking in the dish machine area was discolored; * Spills, splatters, and debris were noted on the magnetic knife holder, microwave front and inside, and the front of the oven; * There was a circular hole in the drywall below the hand washing sink; * Non-Dietary staff, not working in the kitchen, were observed entering and exiting the kitchen; * Dietary staff did not have hair restrained; * Garbage cans lids did not have the required enclosure; * The bulk food bins had spills, splatters, and debris on them; and * There were no test strips available to monitor the sanitizer bucket solution. Staff 1 (ED) and Staff 3 (Director of Health Services) toured the kitchen with the surveyors on 06/02/25 and all above areas were identified. The need to ensure the kitchen was maintained in a sanitary manner and food was stored and prepared in accordance with the Food Sanitation Rules, OAR 333-150-000, was discussed with Staff 1 and Staff 3. They acknowledged the findings. ?2. The Activities Room kitchenette was toured with Staff 1 (ED) at 9:22 am on 06/03/25. She confirmed it was used for light food preparation such as baking cookies and serving drinks. The following areas of concern were identified: Food drips, spills, debris, and paint splashes were observed in and/or on the kitchenette sink, microwave, dishwasher walls, cupboard doors, cupboard interiors, and garbage can. The need to ensure the kitchenette was maintained in a sanitary manner was discussed with Staff 1 on 06/03/25. She acknowledged the findings.

All cleaning and repairs have been made. Test strips are now available for use. Re-education provided to the dietary staff on cleaning schedules/routines, dress code including hair nets and reporting of maintenance needs timely. Re-education was provided to non dietary staff of need to enter only when needed. Routine walk throughs of the kitchen/activity kitchen and review of cleaning schedules will be used for ongoing compliance. Daily/weekly QA tasks and weekly ED review with DSM on kitchen oversight/management ED/DSM

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:? On 09/03/25 at 10:47 am, the kitchen was toured with Staff 11 (Dining Services Manager). The following was identified: * Pipes, walls, gauges, floor drain, and flooring behind/underneath the dish machine and three compartment sink and beside the ice machine and oven had a build up of black matter, food debris, grease, and corrosion; * The caulking in the dish washing area was discolored, had liquified in areas and left a residue on the stainless steel backsplash; and * Black matter, grease and debris were noted on stainless steel shelving above and below the steam table, below the griddle and waffle maker, and inside the large utensil drawer. Staff 1 (ED) toured the kitchen with the surveyor on 09/03/25 at 2:47 pm and all above areas were identified. On 09/03/25 at 2:47 pm, the need to ensure the kitchen was maintained in a sanitary manner in accordance with the Food Sanitation Rules, OAR 333-150-000, was discussed with Staff 1. She acknowledged the findings.

A deep cleaning of the kitchen including the areas noted on the survey visit document was completed on 9/9/2025, 9/10/2025 & 9/12/2025. Cleaning schedules were reviewed to assure a routine for all areas of the kitchen. Re-intruction given to all kitchen cleaning staff provided on cleaning schedules to assure understanding. Daily M-F walkthroughs of the kitchen to verify adherance to the cleaning schedules will be conducted for 30 days then resume as part of the weekly QA Dining Services Manager & Executive Director

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by:

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: ?Based on interview and record review, it was determined the facility failed to ensure the most recent quarterly evaluation was relevant to the needs and condition of the resident for 3 of 4 sampled residents (#s 1, 2, and 4) whose quarterly evaluations were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the community in 04/2021 with diagnoses including dementia with behavioral disturbance and stroke. A review of the resident's most recent quarterly evaluation, dated 03/25/25, as well as interviews with multiple staff members, identified the evaluation was not relevant to the current needs and condition of the resident in the following areas: * Cognitive: behavioral/mood problems; * Bathing preference; and * Nutrition: recent weight loss. On 06/04/25, the need to ensure quarterly evaluations were relevant to the needs and condition of the residents was discussed with Staff 1 (ED), Staff 3 (Director of Health Services), and Staff 4 (Regional Nurse Consultant). They acknowledged the findings. 2. Resident 2 was admitted to the facility in 07/2024 with diagnoses including osteoporosis and stage 3 chronic kidney disease. The resident’s current service plan/quarterly evaluation, dated 04/28/25, and progress notes, temporary care plans (TCPs), and Resident Occurrence Reports dated 03/03/09/25 through 05/28/25 were reviewed. Interviews with staff and the resident were conducted. The quarterly evaluation was not relevant to the needs and current condition of the resident in the following areas: * Emergency department visits on 04/17/25 and 04/24/25; * Use of a wrist call button; * Level of assistance needed for showering; * Need for assistance with dressing; and * Need for assistance with toileting. The need for the quarterly evaluation to include data relevant to the needs and current condition of the resident was discussed with Staff 1 (ED), Staff 3 (Director of Health Services), and Staff 4 (Regional Nurse Consultant) on 06/04/25 at 1:20 pm. They acknowledged the findings. 3. Resident 4 moved into the community in 12/2020 with diagnoses including Multiple Sclerosis. Review of the resident’s quarterly evaluation dated 04/08/25, observations of the resident and interviews with the resident, resident's spouse and direct care staff found the evaluation was not reflective of the current needs and condition of the resident in the following areas: Emergency evacuation procedures; Inability to use right upper extremity to assist with ADLs and bed mobility; and Anti-contracture boots. The need to ensure the quarterly evaluations were relevant to the current needs and condition of the resident was reviewed with Staff 1 (ED), Staff 3 (Director of Health Services), and Staff 4 (Regional Nurse Consultant) on 06/04/25 at 1:00 pm. They acknowledged the findings.

Service plans for sampled residents have been updated to reflect current resident care needs. An audit of remaining residents service plans/quarterly evals was conducted to verify accuracy. Re-education provided to the ALD and RN on quarterly evals/service plan updates process which is designed to assure accuracey in content. Re-education provided to the ALD and RN on routine reviews of TCP's and process of moving info to the residents service plan unless TCP is resolved. Updated quarterly evals/service plans will be reviewed by ALD/RN and ED as they are updated to assure accuracey. Quarterly ALD/RN/ED

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 interview and record review, it was determined the facility failed to ensure service plans were reflective of resident needs and provided clear direction to staff regarding the delivery of services for 3 of 4 sampled residents (#s 1, 2, and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 07/2024 with diagnoses including osteoporosis and stage 3 chronic kidney disease. The resident’s current service plan/quarterly evaluation, dated 04/28/25, and progress notes, temporary care plans (TCPs), and Resident Occurrence Reports dated 03/03/09/25 through 05/28/25 were reviewed. Interviews with staff and the resident were conducted. The service plan was not reflective of the resident’s needs in the following areas: * Emergency department visits on 04/17/25 and 04/24/25; * Use of a wrist call button; * Level of assistance needed for showering; * Need for assistance with dressing; and * Need for assistance with toileting. The need for the service plan to reflect the resident’s needs was discussed with Staff 1 (ED), Staff 3 (Director of Health Services), and Staff 4 (Regional Nurse Consultant) on 06/04/25 at 1:20 pm. They acknowledged the findings. 2. Resident 4 moved into the facility in 12/2020 with diagnoses including Multiple Sclerosis. The resident's current service plan, dated 04/08/25, progress notes dated 03/05/25 through 05/16/25 and temporary care plans (TCPs) were reviewed, interviews with staff were conducted, and observations of the resident were completed. The following was identified: The resident’s service plan was not reflective and/or lacked resident specific direction for staff in the following areas: * Emergency evacuation procedures; * Inability to use right upper extremity to assist with ADLs and bed mobility; and * Anti-contracture boot. The need to ensure residents’ service plans were reflective of current care needs and provided direction to staff was reviewed with Staff 1 (ED), Staff 3 (Director of Health Services), and Staff 4 (Regional Nurse Consultant) on 06/04/25 at 1:00 pm. They acknowledged the findings. 3. Resident 1 moved into the community in 04/2021 with diagnoses including dementia with behavioral disturbance and stroke. The resident’s service plan, dated 03/25/25, was reviewed, observations were made, and interviews were conducted. The resident's service plan was not reflective of the resident’s needs and did not provide clear direction to staff regarding the delivery of services including the who, what, when, how, and how often services shall be provided in the following areas: * Behaviors and behavioral interventions; * Assistance needed for meal attendance; * Clothing preferences; * Breakfast preference; * Assistance needed for laundry; and * Reporting on eating changes. On 06/04/25, the need to ensure service plans were reflective of the residents’ needs and provided clear instruction to staff was discussed with Staff 1 (ED), Staff 3 (Director of Health Services), and Staff 4 (Regional Nurse Consultant). They acknowledged the findings.

Service plans for sampled residents have been updated to reflect current resident care needs. An audit of remaining residents service plans/quarterly evals was conducted to verify accuracy. Re-education provided to the ALD and RN on quarterly evals/service plan updates process which is designed to assure accuracey in content. Re-education provided to the ALD and RN on routine reviews of TCP's and process of moving info to the residents service plan unless TCP is resolved. Updated quarterly evals/service plans will be reviewed by ALD/RN and ED as they are updated to assure accuracey. Quarterly ALD/RN/ED

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by:

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to maintain infection prevention and control to provide a safe, sanitary and comfortable environment for 1 of 1 sampled resident (#4) dependent on staff for ADL care and multiple sampled and unsampled residents who received meal delivery service. Findings include but are not limited to: Resident 4 moved into the facility in 12/2020 with diagnoses including Multiple Sclerosis. 1. During the acuity interview on 06/02/25, Resident 4 was identified as being bedbound and requiring two caregivers for mobility. On 06/04/25 at 9:30 am, ADL observations were made for Resident 4’s treatment application for wounds on buttocks and repositioning in bed with Staff 8 (CG) and Staff 6 (CG). Staff 8 donned single use gloves after entering the room and proceeded to empty the resident’s catheter bag into a container and pour its contents into the toilet. She then proceeded to remove the blankets and pillows from around the resident. The CGs rolled Resident 4 onto his/her side. Staff 8 wiped the resident’s perineal area and, wearing the same soiled gloves, applied ointment and barrier cream to buttock wounds and surrounding skin. The CGs then rolled Resident 4 onto his/her back and repositioned him/her in bed. Staff 8 then cleaned the skin on Resident 4’s chest and groin areas and applied Nystatin powder and moisture strips to skin folds. The CGs adjusted Resident 4’s position in bed and Staff 8 donned anti-contracture boots, fluffed pillows and placed them under the resident’s arms, knees and head, and placed a sheet and blanket over him/her. Staff 8 then used the resident’s bed control to adjust the position of the bed; she then gathered up the trash bag, doffed gloves and threw them in the bag before leaving the room. Staff 8 was not observed to perform hand hygiene prior to leaving the room. The need for the facility to maintain infection prevention and control to provide a safe, sanitary and comfortable environment was reviewed with Staff 1 (ED), Staff 3 (Director of Health Services) and Staff 4 (Regional Nurse Consultant). They acknowledged the findings. ?2. Caregiving staff delivering meals to resident rooms were observed on 06/02/25 and 06/03/25. The following was identified: * The staff lacked a barrier (such as an apron) over potentially contaminated clothing; * Staff were not observed to perform hand hygiene when entering and exiting resident rooms; and * Staff were observed touching the eating end of silverware intended for residents who chose to eat meals in their rooms with their hands. The need to maintain infection prevention and control protocols during room service was discussed with Staff 1 (ED) on 06/04/25. She acknowledged the findings.

Re-education provided to all CG/MT staff on proper glove usage (to include when to change gloves) to assure understanding. Re-education provided to staff involved in the meal process on apron use, proper hand washing (how and when) along with hand hygiene during tray delivery services. Routine observations will be made of caregiving staff during cares to assure adherence to retraining provided. Routine meal observations will be made to assure adherence to retraining. CArgiver skills observations will be conducted twice monthly for 30 days then resume quarterly and/or as needed. Meal observations will be done once daily on a rotation of meal times for 30 days then resume as needed. ED/ALD/DSM

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

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure physician or other legally recognized practitioner orders were carried out as prescribed for 1 of 3 sampled residents (#2) whose MAR and physician orders were reviewed. Findings include, but are not limited to: Resident 2 was admitted to the facility in 07/2024 with diagnoses including osteoporosis and stage 3 chronic kidney disease. The resident’s 05/01/25 through 06/04/25 MARs and current signed physician orders were reviewed, and staff were interviewed. The following was identified: * There was a physician order for oxycodone 5 mg tabs, 0.5 tablet with breakfast; * A physician order for oxycodone 5 mg tabs, 0.5 tablet every six hours as needed for moderate to high/severe pain; and * An order for Colace 100 mg caps, “give 1 tab by mouth everytime [sic] oxycodone is given.” On 05/27/25, Resident 2 was administered oxycodone at the following times: * 1:27 am; * 5:49 am; and * 8:00 am. In addition, Colace was administered to Resident 2 only on 05/28/25 and 05/29/25. The need for physician orders to be carried out as prescribed was discussed with Staff 1 (ED), Staff 3 (Director of Health Services), and Staff 4 (Regional Nurse Consultant) on 06/04/25 at 1:20 pm. They acknowledged the findings.

Re-education provided to all MT staff on reading and following MD orders was conducted. A MAR audit was conducted for remaining residents to assure MD orders are being followed. Ongoing compliance will be maintained through: 1) daily order transcription review to assure orders put on MAR properly 2) Weekly MAR audits to assure MD orders are being followed Daily/weekly ALD/RN with ED oversight

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

OAR 411-054-0090 (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 (OFC), and fire and life safety instruction was provided to staff on alternate months from fire drills. Findings include, but are not limited to: Six months of facility fire drill and fire and life safety records from 11/2024 to 05/2025 were reviewed with Staff 5 (Maintenance Director) on 06/03/25. a. Fire drills records lacked documentation of the following: * Time of day; * Escape route used; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Evacuation time period needed; and * Number of occupants evacuated. b. Staff 5 confirmed there was no documented evidence staff were trained in fire and life safety procedures on alternate months from fire drills. The need to ensure fire drills were conducted per OFC and staff were trained in fire and life safety procedures on alternate months from fire drills was discussed with Staff 1 (ED) on 06/04/25 at 1:00 pm. She acknowledged the findings.

ED has provided re-education to the MD on fire drill/staff training rotation and completion of the required paperwork. ED & MD have review the schedule for drills/training rotation for the balance of 2025 to assure it correct. ED and MD will review for ongoing compliance through weekly QA systems. Weekly ED & MD

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

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents were instructed in fire and life safety procedures at least annually. Findings include, but are not limited to: Facility fire and life safety records were reviewed on 06/03/25. The facility lacked documented evidence residents were instructed in general safety procedures, evacuation methods, and responsibilities at least annually. The need to ensure residents were instructed in fire and life safety procedures annually, was discussed with Staff 1 (ED) on 06/04/25 at 1:00 pm. She acknowledged the findings.

An annual training for 2025 will be conducted by 8/3/25 and scheduled annually thereafter. Re-education conducted with MD on annual resident training requirements to assure understanding. ED & MD will review weekly to assure adherence to fire lift safety events calender for required drills and training. Weekly ED & MD

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 and interview, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 240.

See individual POC for remaing citation noted under C240. ED will review POC with Dining Services Dept daily on days worked to assure adherence. ED will review POC daily and walk kitchen at least 3/weekly for 30 days Executive Director

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:

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 all exterior pathways and accesses were maintained in good repair. Findings include, but are not limited to: The exterior of the facility was toured on 06/02/25. Exterior pathways around the perimeter of the building had drop-offs up to three inches, measured from the concrete to the ground. Observations made on 06/02/25 and 06/03/25 revealed multiple unsampled residents accessed the pathways, including residents with assistive walking devices. The drop-offs created potential fall hazards for residents. On 06/03/25, the building's exterior was toured Staff 1 (ED). She acknowledged the findings.

Drop offs along the exterior pathways have been corrected. Routine walks around the exterior will be conducted to identify potential issues needing resolution. Weekly ED & MD

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:

OAR 411-054-0300 (5) Resident Units (5) RESIDENT UNITS. All resident units must be accessible per building codes. These apartments must have a lockable entry door with lever type handle, a private bathroom, and kitchenette facilities. Adaptable units are not acceptable.(a) UNIT DIMENSIONS. New construction units must have a minimum of 220 net square feet, not including the bathroom. Units in pre-existing structures being remodeled must have a minimum of 160 square feet, not including the bathroom.(b) RESIDENT STORAGE SPACE.(A) Each unit must provide usable space totaling at least 100 cubic feet for resident clothing and belongings and include one clothes closet with a minimum of four linear feet of hanging space.(B) The rod must be adjustable for reach ranges per building codes. In calculating useable space, closet height may not exceed eight feet and a depth of two feet.(C) Kitchen cabinets must not be included when measuring storage space.(D) A lockable storage space (e.g., drawer, cabinet, or closet) must be provided for the safekeeping of a resident ' s small valuable items and funds. Both the administrator and resident may have keys.(c) WINDOWS.(A) Each resident's living room and bedroom must have an exterior window that has an area at least one-tenth of the floor area of the room.(B) Unit windows must be equipped with curtains or blinds for privacy and control of sunlight.(C) Operable windows must be designed to prevent accidental falls when sill heights are lower than 36 inches and above the first floor.(d) DOORS. Each unit must have an entry door that does not swing into the exit corridor.(A) A locking device must be included that is released with action of the inside lever. Locks for the entry door must be individually keyed, master keyed, and a key supplied to the resident.(B) The unit exit door must open to an indoor, temperature controlled, common-use area or common corridor.(e) BATHROOM. The unit bathroom must be a separate room with a toilet, sink, a roll-in curbless shower, towel bar, toilet paper holder, mirror, and storage for toiletry items.(A) The door to the bathroom must open outward or slide into the wall.(B) Showers must have a slip-resistant floor surface in front of roll-in showers, a hand-held showerhead, cleanable shower curtains, and appropriate grab bar.(f) KITCHENS OR KITCHENETTES. Each unit must have a kitchen area equipped with the following:(A) A sink, refrigerator, and cooking appliance that may be removed or disconnected. A microwave is considered a cooking appliance.(B) Adequate space for food preparation.(C) Storage space for utensils and supplies.(D) Counter heights may not be higher than 34 inches. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. Findings include, but are not limited to: The facility was toured on 06/02/25. Resident unit windows on the second floor opened vertically, and windowsills were lower than 36 inches. A random sample of second floor windows throughout the facility, including the common area library and resident-occupied Room 254, were observed to open fully and were not designed to prevent accidental falls. In an interview at 2:28 pm on 06/03/25, Staff 5 (Maintenance Director) confirmed additional resident rooms on the second floor had the same window types and lacked a mechanism to prevent accidental falls. The lack of a system to prevent accidental falls from windows above the first floor and lower than 36 inches from floor to sill was discussed with Staff 2 (ED) on 06/04/25. She acknowledged the findings.

Windows have been secured. Re-education provided to the MD on this rule and routine oversight to assure understanding Routine checks of the windows will be conducted to assure ongoing function Monthly ED /MD

OAR 411-054-0300 (5) Resident Units (5) RESIDENT UNITS. All resident units must be accessible per building codes. These apartments must have a lockable entry door with lever type handle, a private bathroom, and kitchenette facilities. Adaptable units are not acceptable.(a) UNIT DIMENSIONS. New construction units must have a minimum of 220 net square feet, not including the bathroom. Units in pre-existing structures being remodeled must have a minimum of 160 square feet, not including the bathroom.(b) RESIDENT STORAGE SPACE.(A) Each unit must provide usable space totaling at least 100 cubic feet for resident clothing and belongings and include one clothes closet with a minimum of four linear feet of hanging space.(B) The rod must be adjustable for reach ranges per building codes. In calculating useable space, closet height may not exceed eight feet and a depth of two feet.(C) Kitchen cabinets must not be included when measuring storage space.(D) A lockable storage space (e.g., drawer, cabinet, or closet) must be provided for the safekeeping of a resident ' s small valuable items and funds. Both the administrator and resident may have keys.(c) WINDOWS.(A) Each resident's living room and bedroom must have an exterior window that has an area at least one-tenth of the floor area of the room.(B) Unit windows must be equipped with curtains or blinds for privacy and control of sunlight.(C) Operable windows must be designed to prevent accidental falls when sill heights are lower than 36 inches and above the first floor.(d) DOORS. Each unit must have an entry door that does not swing into the exit corridor.(A) A locking device must be included that is released with action of the inside lever. Locks for the entry door must be individually keyed, master keyed, and a key supplied to the resident.(B) The unit exit door must open to an indoor, temperature controlled, common-use area or common corridor.(e) BATHROOM. The unit bathroom must be a separate room with a toilet, sink, a roll-in curbless shower, towel bar, toilet paper holder, mirror, and storage for toiletry items.(A) The door to the bathroom must open outward or slide into the wall.(B) Showers must have a slip-resistant floor surface in front of roll-in showers, a hand-held showerhead, cleanable shower curtains, and appropriate grab bar.(f) KITCHENS OR KITCHENETTES. Each unit must have a kitchen area equipped with the following:(A) A sink, refrigerator, and cooking appliance that may be removed or disconnected. A microwave is considered a cooking appliance.(B) Adequate space for food preparation.(C) Storage space for utensils and supplies.(D) Counter heights may not be higher than 34 inches. This Rule is not met as evidenced by: