OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the local SPD office was immediately notified of any incident of abuse or suspected abuse and investigations of abuse or suspected abuse included follow up action by the facility for 1 of 1 sampled residents(# 1) whose incidents were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the community in 10/2023 with diagnoses including generalized weakness. The resident was noted to experience pain to the left arm due to a recent fracture. Resident 1 had a signed physician's order for hydrocodone-acetaminophen 5-325 mg, half tablet, four times a day after meals and at bedtime. On 09/02/25 a MT administered a full tablet of hydrocodone-acetaminophen 5-325 mg after breakfast, instead of the half tablet as prescribed. An 09/03/25 investigation into the medication error noted at the following: * “ [MT] stated she didn’t know that 0.5 [tablet] meant half [tablet] and was confused”; and * “Discovered by RN and RCC when staff reported [Resident 1] was acting [different] during lunch and was leaning over in his/her wheelchair. Confirmed by counting [narcotic] book and looking at [narcotic] cards. There was no documented evidence of follow up action by the facility or showing the incident was immediately reported to the local SPD office. During an interview at 10:48 am on 11/06/25/25, Staff 1 (Administrator) confirmed the incident had not been reported to the local SPD office. The surveyor requested the incident be reported to the local SPD office, and confirmation was received prior to survey exit. The need to ensure incidents of abuse or suspected abuse were immediately reported to the local SPD office and investigations into abuse or suspected abuse included documentation of follow up action by the facility was reviewed with Staff 1 and Staff 2 (Wellness Director), on 11/06/25 at 12:28 pm. They acknowledged the findings.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the local Seniors and People with Disabilities (SPD) office was immediately notified of any incident of abuse or suspected abuse and investigations of abuse or suspected abuse included follow-up action by the facility for 1 of 1 sampled resident (#1) whose incidents were reviewed. 1. The Administrator reported the incident to the local SPD office prior to survey exit. 2. Staff training on Elder Abuse Prevention, Investigation, and Reporting. 3. Administrator, Community Nurse, and Resident Care Coordinators will review the incident log daily. 4. The Administrator is responsible for carrying out the corrections.

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 and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: Observations of the facility kitchen, food storage areas, and food preparation throughout the survey, 11/03/25 through 11/05/25, revealed the following: a. A build-up of black matter, splatters, spills, drips, and/or debris on: * Upper and lower stainless steel shelves throughout the entire kitchen; * Stainless steel backsplash in dish washing area; * Stove/oven doors and sides; * Counter/prep area interior and exterior drawers; * Interior of ice machine; and * Flooring throughout the entire kitchen, including in the walk-in refrigerator, walk-in freezer, ceramic floor drains, dry storage area, underneath prep areas, sinks, service area dishwashing area, and behind cooking equipment. b. Improper food storage: * Food stored in walk -in refrigerator and white deep freezer lacked labels, dates, and/or was not covered. c. The two-door refrigerator was observed not in good repair. d. There were flies noted in the kitchen throughout the survey. The areas of concern were observed and discussed with Staff 4 (Dietary Manager) on 11/04/25 at 9:15 am and with Staff 1 (ED) on 11/05/25 at 2:45 pm. They acknowledged the findings.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. 1. All areas identified in the Statement of Deficiencies will be cleaned. All unlabeled food will be discarded. The two-door refrigerator, which is observed to be not in good repair, will be repaired or removed from the facility. The facility will use Sprague Pest Control to evaluate and treat the fly issue. 2. The Dietary Manager will develop and implement daily and weekly cleaning checklists and train the kitchen staff on the performance of cleaning duties. Dietary Manager and staff will be trained on Keeping Food Safe and Nourishing for Older Adults. 3. The Dietary Manager and Administrator will perform daily and weekly unannounced, non-routine audits of the kitchen. 4. The Dietary Manager and the Administrator will be responsible for carrying out the corrections.

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 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused to consent to orders for 2 of 2 sampled residents (#s 5 and 6) who had documented medication and treatment refusals. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 06/2025 with diagnoses including left sided hemi-paresis secondary to stroke. The resident's 10/01/25 through 11/03/25 MARs and progress notes dated 08/06/25 through 10/30/25 were reviewed and revealed the resident refused to consent to orders for the following medications: * Carvedilol (for high blood pressure) on nine occasions; * Ketoconazole 2% cream (for skin care) on 54 occasions; * Flonase nasal spray (for allergy relief) on 28 occasions; * Ketonazole 2% shampoo (for scalp care) on nine occasions. In an interview on 11/05/25 at 3:35 pm, Staff 14 (MT) indicated the physician was not notified when the residents refused “cream, but if it was a medication, then we fax the physician.” In an interview on 11/06/25 at 12:00 pm, Staff 2 (Wellness Director) acknowledged there was no documented evidence the physician was notified of the refusals for the medications and/or treatments. No additional documentation was provided. The need to ensure the facility notified the physician or other practitioner if the resident refused consent to an order was discussed with Staff 1 (ED) and Staff 2 (Wellness Director) on 11/06/25 at 12:30 pm. The findings were acknowledged. 2. Resident 6 was admitted to the facility in 09/2021 with diagnoses including congestive heart failure. The resident's 10/01/25 through 11/03/25 MARs and progress notes dated 08/06/25 through 10/30/25 were reviewed and revealed the resident refused to consent to orders for the following treatments: * Daily morning weights (for high blood pressure) were refused on 10 occasions; and * Nystatin powder (for fungal skin infection) was refused on seven occasions. There was no documented evidence the prescriber was notified after each refusal for the above treatments. The need to notify the physician or other practitioner of resident medication refusals was discussed with Staff 1 (ED) and Staff 2 (Wellness Director) on 11/06/25 at 12:30 pm. The findings were acknowledged.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused to consent to orders for 2 of 2 sampled residents (#s 5 and 6) who had documented medication and treatment refusals. 1. Medication Aides, Wellness Director, and Resident Care Coordinators will be trained on the Basics of Medication Management to highlight the importance of ensuring the facility notifies the physician or other practitioner if the resident refuses consent to an order. 2. Daily, the Wellness Director will audit medication refusals and provider notifications. 3. Weekly, the Administrator will audit medication refusals and provider notifications. 4. The Administrator is responsible for carrying out the corrections.

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

OAR 411-054-0060 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 potentially restraining qualities was assessed by an RN, PT, or OT, other less restrictive alternatives evaluated prior to use of the device were documented, caregivers were instructed on the correct use of and precautions for the device, and use of the device was included in the resident's service plan for 1 of 1 sampled resident (#6) who had side rails on his/her bed. Findings include, but are not limited to: Resident 6 was admitted to the facility in 09/2021 with diagnoses including congestive heart failure. Observations of the resident and the resident's apartment on 11/04/25 at 10:20 am showed ¾ side rails were on each side of the bed, one in the up position against the wall, and represented a device with restraining qualities. Resident 6 confirmed both rails are in the up position when s/he was in bed. Review of Resident 6's record revealed there was no documented evidence the device with restraining qualities had been assessed by an RN, PT, or OT, there was no documentation other less restrictive alternatives were evaluated prior to use of the devices, there was no documentation of instruction to caregivers on correct use of and precautions for the device, and there was no documentation of the use of the side rails in the resident's service plan. In an interview on 11/05/25 at 11:30 am, Staff 2 (Wellness Director) acknowledged no assessment had been completed for Resident 6's side rails. The need to ensure the use of a supportive device with potentially restraining qualities included documentation of all required elements and was included in the resident's service plan was discussed with Staff 1 (ED) and Staff 2 on 11/06/25 at 12:30 pm. They acknowledged the findings.

OAR 411-054-0060 Restraints and Supportive Devices 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 potentially restraining qualities was assessed by an RN, PT, or OT, other less restrictive alternatives evaluated prior to use of the device were documented, caregivers were instructed on the correct use of and precautions for the device, and use of the device was included in the resident's service plan for 1 of 1 sampled resident (#6) who had side rails on his/her bed. 1. The Wellness Director completed a device with restraining qualities assessment for resident 6. 2. The Wellness Director will complete training on The Role of Service Plans. 3. The Wellness Director will audit for devices with restraining qualities during all new admissions and quarterly assessments. 4. The Administrator will be responsible for carrying out the corrections.

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 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to complete an acuity-based staffing tool (ABST) that accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan for 4 of 6 sampled residents (#s 1, 2, 3, and 5) whose ABST records were reviewed. Findings include, but are not limited to: Resident 1, 2, 3, and 5’s service plans, Interim Service Plans (ISPs), and corresponding ABST individual minutes were reviewed. The residents were observed, and interviews were conducted with staff. The residents’ care times and care elements were found to not be reflective in one or more of the following areas: * Ambulation to and from meals; * Responding to call lights; * Two-person transfers; * Transferring in or out of bed or chair; * Repositioning in bed or chair; * Non-drug interventions for behaviors; and * Medication administration. The need to ensure the facility ABST accurately captured care time and care elements that staff were providing was discussed with Staff 1 (ED) and Staff 2 (Wellness Director) on 11/06/25. They acknowledged the findings.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to complete an acuity-based staffing tool (ABST) that accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan for 4 of 6 sampled residents (#s 1, 2, 3, and 5) whose ABST records were reviewed. 1. The Administrator updated the facilities ABST tool to account for the residents’ care times and care elements that were found to not be reflective in one or more of the following areas: Ambulation to and from meals; Responding to call lights; Two-person transfers; Transferring in or out of bed or chair; Repositioning in bed or chair; Non-drug interventions for behaviors; and Medication administration. 2. The Administrator and Wellness Director will update the ABST in coordination if either the resident's service plan changes or the quarterly assessment is completed. In addition, they will update the ABST before admission and at admission for new residents. 3. The Administrator and Wellness director will audit the ABST weekly. 4. The Administrator will be responsible for carrying out the corrections.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by:

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure pre-service orientation topics and training had been completed prior to staff beginning job duties for 2 of 4 newly hired caregiving staff (#s 8 and 9). Findings include, but are not limited to: Review of the facility's training records on 11/05/25 indicated the following: There was no documented evidence Staff 8 (CG), hired 09/02/25, and Staff 9 (MT), hired 06/24/25, had completed the following: * Abuse reporting requirements; * Infectious Disease Prevention (2-hour course); * Approved HCBS course; and * Approved LQBTQIA2S+ course. Requirements for pre-service training were reviewed with Staff 1 (ED) and Staff 2 (Wellness Director) on 11/06/25. They acknowledged the findings.

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure pre service orientation topics and training had been completed prior to staff beginning job duties for 2 of 4 newly hired caregiving staff (#s 8 and 9). 1. Staff numbers 8 and 9 were assigned and will complete the missing training via Oregon Care Partners. 2. The BOM has an Excel spreadsheet and a staff training binder to help keep track of assigned trainings. 3. The BOM will audit assigned training for all care staff weekly. 4. The Administrator will be responsible for carrying out the corrections.

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by:

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#’s 7, 8, and 9) demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to: Training records were reviewed on 111/05/25 and the following was identified: There was no documented evidence Staff 7 (CG), hired on 07/30/25, Staff 8 (CG), hired on 09/02/25, and Staff 9 (MT), hired on 06/24/25, demonstrated competency in the following areas: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; and * First Aid and abdominal thrust. The need to ensure staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 1 (ED) and Staff 2 (Wellness Director) on 11/06/25. They acknowledged the findings.

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#’s 7, 8, and 9) demonstrated competency in all assigned job duties within 30 days of hire. 1. Staff were assigned and willl complete training regarding the Role of service plans in providing individualized care; Providing assistance with ADLs; Changes associated with normal aging; Identification, documentation and reporting of changes of condition; and First Aid and abdominal thrust. 2. The BOM has an Excel spreadsheet and a staff training binder to help keep track of assigned trainings. 3. The BOM will audit assigned training for all care staff weekly. 4. The Administrator will be responsible for carrying out the corrections.

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 4 caregiving staff (#s 16, 17, and 18) demonstrated satisfactory performance in all required areas within 30 days of hire. This is a repeat citation. Findings include, but are not limited to: Training records, reviewed on 04/15/26, revealed the following: a. There was no documented evidence Staff 17 (MT), hired 01/14/26, and Staff 18 (CG), hired 03/13/26, had completed First Aid certification and abdominal thrust training. b. There was no documented evidence Staff 16 (MT), hired 01/28/26, had demonstrated competency in: * Providing assistance with ADLs. The need for the facility to have a system to ensure staff training was completed and documented within the required time frame was reviewed with Staff 1 (ED) on 04/15/26 at 4:35 pm. He acknowledged the findings.

1. Staff numbers 16, 17, and 18 completed required training, such as First Aid & Abdominal Thrust, and training to demonstrate competency in providing assistance with ADLs. 2. The BOM has an Excel spreadsheet and a staff training binder to help keep track of assigned trainings. 3. The BOM will audit assigned training for all care staff weekly. 4. The Receptionists and Wellness Director will audit trainings weekly. 5. The Administrator will be responsible for carrying out the corrections.

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by:

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to conduct unannounced fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to: The previous six months of fire drill and fire and life safety training records were reviewed on 11/05/25 with Staff 1 (ED). The following deficiencies were identified: Staff did not consistently evacuate or relocate residents during all fire drills. Therefore, fire drill records did not include information on: * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Evacuation time period needed; * Number of occupants evacuated; and * Alternate routes used. The need to ensure the facility conducted unannounced fire drills according to the OFC was discussed with Staff 1 on 11/05/25. The findings were acknowledged. No further information was provided.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to conduct unannounced fire drills according to the Oregon Fire Code (OFC). 1. Staff will consistently evacuate or relocate residents during all fire drills. Therefore, fire drill records will include information on: problems encountered and comments regarding residents who resisted or failed to participate in the drills; the evacuation time period required; the number of occupants evacuated; and the Alternate routes used. 2. The facilities' fire drill documentation will be updated to include problems encountered, comments on residents who resisted or failed to participate in the drills, and the alternate routes used. 3. The Administrator will audit monthly fire drill documentation. 4. The Administrator will be responsible for carrying out the corrections.

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 conduct fire drills according to the Oregon Fire Code (OFC). This is a repeat citation. Findings include, but are not limited to: Fire drill records for 01/2026 and 02/2026 were reviewed on 04/15/26. The following deficiencies were identified: Staff did not evacuate or relocate residents during the two fire drills reviewed. Therefore, fire drill records did not include information regarding: * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Evacuation time period needed; * Number of occupants evacuated; and * Alternate routes used. On 04/15/26 at 2:20 pm, Staff 6 (Maintenance Director) confirmed residents were not involved in the 01/2026 or 02/2026 fire drills, and the required elements were not documented. The need to ensure the facility conducted fire drills according to the OFC was discussed with Staff 1 (ED) on 04/15/26 at 5:18 pm. He acknowledged the findings.

1. Staff will consistently evacuate or relocate residents during all fire drills. Therefore, fire drill records will include information on: problems encountered and comments regarding residents who resisted or failed to participate in the drills; the required evacuation time period; the number of occupants evacuated; and the Alternate routes used. 2. The facilities' fire drill documentation will be updated to include problems encountered, comments on residents who resisted or failed to participate in the drills, and the alternate routes used. 3. The Administrator will audit monthly fire drill documentation. 4. The Administrator will be responsible for carrying out the corrections.

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 411-054-0105 (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 interview and record review, 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: C372 and C420.

Refer to: C372 and C420

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 (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 all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: The facility was toured on 11/03/25 and 11/04/25. The following issues were identified: * There were dark spots and stains on the carpet in first floor hallways starting outside apartment 121 and continuing down the next hallway ending at apartment 140; * The living room window in apartment 114 was covered with debris and grime; and * Apartment 239 was missing a bathroom door. In an interview with an unsampled resident on 11/06/25 at 9:55 am, s/he stated s/he had no bathroom door in their unit. The resident stated it had been like that “for three years.” On 11/06/25 at 10:06 am, in an interview with Staff 1 (ED), he confirmed the unsampled resident did not have a bathroom door. The areas needing repair were reviewed with Staff 1 and Staff 6 (Maintenance Director) on 11/04/25. They acknowledged the areas needing cleaning and repair. Findings regarding the missing door and dirty window were reviewed with Staff 1 on 11/06/025. He acknowledged the findings.

OAR 411-054-0300 (4)(d-i) General Building: Doors - Walls, Cleanable. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. 1. The carpet in the first-floor hallways, starting outside apartment 121 and continuing down the next hallway to apartment 140, was shampooed. The living room window in apartment 114 was cleaned. The missing bathroom door in apartment 239 will be replaced. 2. The facility will hire an additional housekeeper, and one of their tasks will be daily cleaning of common-area carpets. The facility will create a daily and a weekly common-area cleaning task list. The Maintenance Director will audit residents' apartments to ensure all units have the necessary doors. 3. The Maintenance Director will audit the cleaning task list daily and weekly. 4.The Administrator will be responsible for carrying out the corrections.

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:

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure residents rights of privacy in his or her own unit for one unsampled residents. Findings include, but are not limited to: Refer to C613.

Please refer to C613.

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by: