OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure residents' right to have medical and other records kept confidential except otherwise provided by law for multiple unsampled residents. Findings include, but are not limited to: On 02/25/26 at 12:20 pm and 2:30 pm, three empty prescription bottles/boxes with labels including resident’s protected health information (PHI) were noted on top of an unattended medication cart in Cottage B. The same prescription bottles were noted on the same unattended medication cart on 02/26/26 at 9:00 am and 10:26 am. On 02/25/26 from 2:35 pm until 3:00 pm, the following was noted while observing Staff 6 (MT): * MT’s computer screen was left open and unattended with five residents and access to their PHI visible on the screen; * Medication administration records and empty medication cards with residents’ PHI were left unattended on the cart; and * Staff 3 (RCC) approached the unattended medication cart, retrieved an item, and left the medication administration records and empty medication cards on the cart. On 02/25/26 at 3:23 pm, a power of attorney form for an unsampled resident and PHI related to several residents’ diagnoses, diet, weight, and dates of birth was observed on an unsecured cabinet shelf in Cottage A’s dining room. From 02/24/26 through 02/27/26, PHI related to wounds and wound care was observed hanging on the exterior of an unsampled resident’s unit door. PHI related to diagnoses and allergies was also observed on a bulletin board by the exit to the balcony patio, in Cottage B. On 02/26/26 at 10:30 am, PHI related to hospice care for several residents was observed hanging on the bulletin board in the dining area in Cottage A. The need to ensure the residents' right to have medical and other records kept confidential except otherwise provided by law was discussed with Staff 1 (ED) on 02/25/26 at 1:10 pm and 02/26/26 at approximately 11:00 am. She acknowledged the findings.

1-All medication bottles and boxes with resident identifying information were immediately removed from public areas and disposed of according to facility policy to protect resident confidentiality. 2-A review of medication storage and disposal procedures was conducted with all staff. Staff were instructed that medication containers with resident information must never be left in common areas and must be disposed of in designated medication disposal containers. 3-Weekly Environmental checks will be conducted to ensure no resident information is visible or accessible in common areas. 4-Executive director and resident care coordinator

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

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure residents received services in a manner that protected privacy and dignity for 2 of 2 sampled residents (#s 4 and 9) and provided a homelike environment for multiple unsampled residents. Findings include, but are not limited to: 1.Resident 4 was admitted to the facility in 07/2025 with diagnoses which included insulin dependent diabetes. Resident 4 was observed on 08/31/26 in Building A dining room just prior to the noon meal. During the observation, Staff 4 (MT) checked the resident’s blood sugar and gave him/her an insulin injection. Several residents were in the dining room, either at the same table or adjacent tables, and could have observed the task being performed. On 09/01/26 at 12:10 pm, the surveyor observed Staff 5 (MT) check the resident’s blood sugar and give him/her an insulin injection in the dining room. One resident, sitting at the same table, observed the task. Several other residents were seated in the dining room awaiting lunch service and could have observed the exchange. Performing a treatment task in the dining room did not provide Resident 4 privacy or dignity, nor did it provide a homelike meal experience for other residents in the dining room. The need to ensure residents received services in a manner that protected privacy and dignity and provided a homelike environment was reviewed with Staff 1 (ED) on 09/02/26 at 11:20 am. She acknowledged the findings. 2. Resident 9 was admitted to the facility in 02/2023 with diagnoses which included dementia. Interviews with staff during the survey revealed s/he required full assistance with ADLs, including incontinence care. On 08/01/26 at 11:20 am, the surveyor obtained permission to observe care. The resident’s bedroom area had a large window with the privacy shade open. This allowed anyone walking outside to see into the room. As Staff 16 and 21 (CGs) initiated care for the resident, the surveyor intervened and asked that the window shade be closed to afford privacy for the resident. Staff 21 closed the shade and care resumed. The need to ensure Resident 9 received services in a manner that protected privacy and dignity was discussed with Staff 1 (ED) on 09/02/26 at 10:10 am. She acknowledged the findings.

1. Resident 4: CBG checks and insulin administration will be performed in the residents’ room or another private area, not in the dining room. Resident 9: staff will close the privacy shade/door before providing incontinence care, personal care, or other ADL services. All staff will be re-educated on resident rights, privacy, dignity, and maintaining a homelike environment. 2. The facility will implement a privacy-before-care process: before any treatment, medication task involving exposure, CBG/insulin administration, or ADL/incontinence care, staff must move to a private area and close doors/shades. Resident-rights/privacy expectations will be included in orientation and reinforced during staff meetings and competency observation. 3. The ED will complete privacy and dignity observations on all shifts weekly for 4 weeks, then monthly for 3 months. Any concern will be corrected immediately and re-education documented. 4. ED, with the RCC, RN/LN assisting with clinical-care observations and staff education.

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

OAR 411-054-0028 (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, interview, and record review, it was determined the facility failed to investigate incidents to rule out abuse and/or report to the local Department office if abuse could not be ruled out for 1 of 1 sampled resident (#7) reviewed for injuries of unknown cause and medication errors. Findings include, but are not limited to: Resident 7 was admitted to the facility in 09/2022 with diagnoses including multiple sclerosis, functional quadriplegia, and osteoporosis. Resident 7 was dependent on staff for ADL care. a. On 08/31/26 at 10:32 am, during incontinence care, the resident was observed wearing a brace on the right lower leg. Resident 7’s progress notes, dated 06/26/26 through 08/31/26, and incident reports, dated 07/08/26 through 08/25/26, were reviewed, and the following was identified: * 07/08/26 – the resident complained of right knee pain. The right knee was noted to be swollen and mildly red. The resident was unable to bend the knee normally; * 07/10/26 – the resident was sent to the hospital and an X- ray was performed. The results indicated a fracture of the right lower leg; * 08/27/26 – the facility was unable to determine the cause of the injury; and * There was no documented evidence the incident was reported to the local Department office and no immediate investigation completed to reasonably rule out abuse. The facility was asked to report the injury to the local Department office on 09/01/26. Confirmation of the report was received on 09/01/26 at 11:54 am. The need to investigate injuries of unknown cause immediately and report the incident to the local Department office if abuse or neglect could not be ruled out was discussed with Staff 1 (ED) on 09/02/26 at 9:20 am. The staff acknowledged the findings. b. Resident 7’s MAR from 08/01/26 through 08/31/26 and the physician orders were reviewed, and the following was identified: * The physician order indicated to administer baclofen 40 mg (to help relax certain muscles) by mouth at bedtime; * There was no documentation on the MAR indicating the medication was administered in 08/2026; and * The surveyor notified the facility, and the facility conducted an investigation. The facility was requested to notify the Department office of the incidents. Confirmation of the reporting was received on 09/02/26 at 9:15 am. No negative outcome to the resident was identified as a result of the medication errors. The need to promptly investigate and report medication errors that could have a negative effect on the resident was discussed with Staff 1 (ED) on 09/02/26 at 9:15 am. The staff acknowledged the findings.

1. Resident 7: the injury of unknown cause was reported to the local Department office on 09/01/26, and the medication-error concern was reported on 09/02/26. The facility will complete/document investigations for injuries of unknown cause and medication errors, including assessment, witness/staff statements, notifications, follow-up, and administrator review, and will report when abuse/neglect cannot reasonably be ruled out or when otherwise required. 2. The incident process will be revised so staff immediately notify the ED/RN of injuries of unknown cause, suspected abuse/neglect, and medication errors. The ED/designee will review each incident before closure using an investigation checklist to verify investigation, required Department reporting, provider/family notifications, follow-up, and service-plan updates. Staff will be trained in mandatory reporting and incident documentation. 3. The ED will review incident reports each business day and audit all incidents weekly for 8 weeks, then monthly for 3 months. Any missing investigation or required report will be completed immediately and staff re-educated. 4. ED, RN/LN will assist with clinical review, medication-related follow-up, and resident assessments.

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 411-054-0034 (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 observation, interview, and record review, it was determined the facility failed to ensure a resident move-in evaluation addressed all required elements for 1 of 1 sampled resident (#3), and failed to ensure significant change of condition or quarterly evaluations were reflective of current care needs for 2 of 2 sampled residents (#s 1 and 2) whose most recent evaluations were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 2021. During the entrance conference on 02/24/26, staff reported the resident had a recent significant decline in health status and was currently receiving hospice services. Review of Resident 1’s clinical record, interviews with care staff, and observations of the resident during the survey revealed s/he was admitted to hospice on 02/12/26, received full assistance with all ADL care needs, and received bathing assistance from hospice staff. Resident 1's most recent evaluation, reviewed and signed by Staff 1 (ED) on 02/25/26, revealed it was not reflective of his/her needs in the following areas: * Bathing assistance; * Grooming assistance; * Transfer assistance and ambulation; * History of falls; * Continence status and assistance with toileting; * Eating and drinking assistance; * Ability to use call light; * Leaving facility with family for “lunch and coffee”; * Use of Warfarin (anticoagulant); * Use of pain medication; and * Hospice services. The need to ensure the evaluation was reflective of Resident 1's current care needs was discussed with Staff 1 (ED) during an interview on 02/25/26 at 12:10 pm. She acknowledged the findings. 2. Resident 2 was admitted to the facility on 04/2025 and had diagnoses which included Parkinson’s and Alzheimer’s dementia. Resident 2’s clinical record, interviews with care staff, and observations of the resident during the survey revealed s/he received assistance with ADL care needs in multiple areas and had a history of falls. Resident 2's most recent evaluation, dated 02/16/26, was not reflective of his/her needs in the following areas: * Side rail use: evaluation noted the resident used side rails when s/he did not; * Multiple falls; * Weight loss; * Nutritional supplement drink; and * Home health services. The need to ensure the evaluation was reflective of Resident 2's current care needs was discussed with Staff 1 (ED) during an interview on 02/26/26 at 1:55pm. She acknowledged the findings. 3. Resident 3 moved into the facility in 02/2026 with diagnoses including dementia without behavioral disturbance and Parkinson’s disease. The initial evaluation, dated 01/23/26, failed to address the following required elements: * Customary routines, including eating and bathing routines; * Visits to health practitioners, emergency room, hospital or nursing facility in the past year; * Personality, including how a person copes with change or challenging situations; * Activities of daily living, including transfer status; * Environmental factors that impact a resident’s behavior, including noise, lighting and room temperature; * Preferred name; * Pronouns; and * Gender identity. The need to ensure the initial evaluation addressed all required elements was discussed with Staff 1 (ED) on 02/25/26 at 1:15 pm. She acknowledged the findings.

1-The evaluations for the residents identified in the survey were immediately reviewed and updated to accurately reflect their current care needs and conditions. 2-All resident evaluations in the facility were reviewed to ensure: •Move-in evaluations contain all required elements •Quarterly evaluations are completed timely •Evaluations reflect the resident's current condition and care needs 3-ED will conduct monthly chart audits to ensure resident evaluations are completed and updated according to OAR requirements. 4-Executive Director and RN

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

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and implemented for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 2021 with diagnoses which included high blood pressure and skin cancer. During the entrance conference on 02/24/26, staff reported the resident had a recent significant decline in health and was currently receiving hospice services. Review of Resident 1’s clinical record, interviews with care staff, and observations of the resident during the survey revealed s/he was admitted to hospice on 02/12/26, received full assistance with all ADL care needs, and received bathing assistance from hospice staff. Resident 1's current service plan, updated 02/12/26, was not reflective of the following areas: * Ability to use his/her call light to summon assistance; * Participation in activities; * Meal assistance; * Grooming assistance; * Sleeping preferences; and * Bathing assistance. The need to ensure the service plan was reflective of Resident 1's current needs was discussed with Staff 1 (ED) on 02/25/26 at 12:10 pm. Staff 1 acknowledged the service plan was not reflective in several areas and needed to be updated. No further information was provided. 2. Resident 2 was admitted to the facility on 04/2025 and had diagnoses which included Parkinson’s disease and Alzheimer’s dementia. Review of the resident’s clinical record, interviews with direct care staff, and observations of Resident 2 during the survey revealed s/he was incontinent, dependent on staff for most ADL care needs, had weight loss, drank a nutritional supplement, and had a history of falls. Resident 2's service plan dated 11/01/25, and a temporary service plan dated 12/12/25, was not reflective of the resident's needs or was not implemented in the following areas: * A temporary service plan instructed staff to “monitor meal intake and document percentage consumed.” Interviews with care staff during the survey revealed this was not being done; and * The service plan indicated the resident used a bed and chair alarm to alert staff when s/he “attempts to get up…” In an interview with Staff 1 (ED) on 02/26/26 at 1:55 pm, she stated the resident no longer used the alarms. The need to ensure the service plan was reflective of Resident 2's current care needs and was implemented was discussed with Staff 1 (ED) during an interview on 02/26/26 at 1:55pm. She acknowledged the findings.

1-Service plans for the residents reviewed during the survey were updated to reflect their current care needs. 2-All resident service plans were reviewed to ensure: •Service plans are updated quarterly •Changes are dated and initialed •Historical information is maintained 3-Will do Monthly chart audits to verify service plans are updated and compliant 4- Executive Director , RCC and RN

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 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to monitor a resident consistent with evaluated needs and service plan for 1 of 1 sampled resident (#2) who experienced short-term changes of condition related to multiple falls. Findings include, but are not limited to: Resident 2 was admitted in 04/2025 with diagnoses including Parkinson’s disease, Alzheimer’s dementia, and had a history of falls. Resident 2's clinical record, service plan, temporary service plans, incident reports, and charting notes reviewed from 12/02/25 through 02/20/26, revealed the following: Resident 2 fell five times between 12/02/25 and 02/14/26. There was no documented evidence the facility consistently monitored fall interventions identified on the service plan or temporary service plans for implementation and effectiveness consistent with the resident’s evaluated needs and service plan. The need to ensure the facility monitored fall interventions consistent with evaluated needs and service plan was discussed with Staff 1 (ED) on 02/27/26 at 8:15 am. She acknowledged the findings.

1-Resident records were reviewed and documentation was corrected to ensure care plans and evaluations accurately reflect resident needs. 2-The facility implemented a documentation review process to ensure: •Resident condition changes are documented promptly •Care plans are updated accordingly •Staff communicate changes in resident status. 3-Executive Director will conduct monthly documentation audits. 4-Executive Director

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

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: A. Based on interview and record review, it was determined the facility failed to ensure significant change of condition assessments, which included documented findings, resident status and interventions made as a result of the assessment, were completed or completed timely by a facility RN, and that the licensed nurse participated on the service planning team or reviewed the service plan within 48 hours, for 2 of 2 sampled residents (#s 1 and 2) reviewed for significant changes of condition. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 2021 with diagnoses which included high blood pressure and skin cancer. During the entrance conference on 02/24/26, staff reported the resident had a recent significant decline in health and was currently receiving hospice services. Review of Resident 1’s clinical record revealed the following: * S/he had a significant decline in health status and was admitted to hospice on 02/12/26. The decline in health and admission to hospice constituted a significant change in condition for which a timely RN assessment which included documented findings, resident status and interventions made as a result of the assessment was required, and that the licensed nurse participated on the service planning team or reviewed the service plan within 48 hours; * There was no documented evidence the facility RN conducted an assessment until 02/24/26 (completed during survey); and * There was no documented evidence the licensed nurse participated on the service planning team or reviewed the service plan within 48 hours. During an interview on 02/25/26 at 12:10 pm, Staff 1 (ED) reviewed the record and acknowledged the RN assessment had not been completed timely, nor had the licensed nurse participated on the service planning team or reviewed it within 48 hours. She added that Staff 2 (RN) was on vacation during that period, and Staff 1 failed to notify the on-call RN to come in, assess the resident, and review the plan of care. The need to ensure RN assessments were completed timely by a facility RN, and that the licensed nurse participated on the service planning team or reviewed the service plan within 48 hours was reviewed during the exit conference on 02/27/26 with Staff 1 (ED) and Staff 2 (RN). The findings were acknowledged. 2. Resident 2 was admitted in 04/2025 with diagnoses including Parkinson’s and Alzheimer’s dementia. During the entrance conference on 02/24/26, staff reported the resident had a recent significant overall decline in health related to weight loss. The clinical record, from 12/2025 through 02/24/26, was reviewed during the survey and revealed the following: * Weight records indicated the resident’s weights as follows: - 08/2025: 196.8 lbs; - 09/2025: 196 lbs; - 10/2025: 195.9 lbs; - 11/2025: no weight recorded; - 12/12/25: 180.2 lbs. (15.7 lb. loss); - 01/27/26: 176 lbs. (4.2 lb. loss); and - 02/26/26 (weight obtained during survey) 174 lbs. (2 lb. loss). * Between 10/2025 and 12/12/25, the resident lost 15.7 pounds, or 8% of his/her total body weight, in two months. This constituted a severe loss and a significant change in condition that required an RN assessment, which included documented findings, resident status, and interventions made as a result of the assessment, in addition to a licensed nurse participating on the service planning team or reviewing the service plan with date and signature within 48 hours. Although Staff 3 (RCC) initiated a temporary service plan on 12/12/25, there was no evidence the facility RN performed an assessment of the resident’s severe weight loss or that a licensed nurse participated on the service planning team or reviewed the service plan within 48 hours. Additional information was requested on 02/27/26. The resident was observed in the dining room during the noon meal on 02/24/26. Staff provided intermittent cueing and meal assistance, and s/he consumed approximately 75%. During an interview on 02/27/26 at 8:15 am, Staff 1 (ED) reviewed the record and acknowledged the lack of an RN assessment which included documentation of findings, the resident's status, and interventions made as a result of the assessment for the significant change in condition, and the lack of documented evidence a licensed nurse participated on the service planning team or reviewed the service plan within 48 hours. Staff 2 (RN) was interviewed via telephone on 02/27/26 at 9:35 am. She stated she worked “limited hours” and that an RN assessment had not been completed because the facility did not inform her of the weight loss. The need to ensure significant change of condition assessments, which included documented findings, resident status, and interventions made as a result of the assessment, were completed by an RN, and that the licensed nurse participated on the service planning team or reviewed the service plan within 48 hours was reviewed with Staff 1 (ED) and Staff 2 (RN) during the exit conference on 02/27/26. The findings were acknowledged. B. Based on interview and record review, it was determined the facility failed to ensure regularly scheduled licensed nursing for onsite duties and failed to ensure an adequate number of nursing hours relevant to the acuity of the resident population. Findings include, but are not limited to: During the survey, the facility was home to 26 residents. The entrance conference acuity interview was conducted with Staff 1 (ED) and Staff 5 (MT) on 02/24/26. During the interview, Staff 1 and 5 identified 17 residents with heavy care needs. Review of the posted staffing plan indicated “Registered Nurse visits for 10-16 hours per week.” During an interview with Staff 1 on 02/26/26 at 9:40 am, she stated Staff 2 (RN) “usually comes in on the weekends” but was not sure exactly what hours she worked. The surveyor requested documentation of licensed nurse hours worked for the past three months. On 02/26/26, Staff 1 provided Staff 2’s days and hours worked from 11/25/25 through 02/25/26. According to the documentation, Staff 2 worked the following days/hours: * 11/25/25: two hours; * 12/03/25: one hour; * 01/20/26: one hour; * 01/23/26: two hours; * 01/24/26: one hour; and * 02/25/26: one hour. From 11/25/25 through 02/25/26, the facility RN worked eight hours. In an interview on 02/26/26 at 2:00 pm, the discrepancy between posted RN hours and actual hours worked was reviewed. Staff 1 said, “I thought she was coming in on the weekends and staying the entire day. I know I need more RN hours. We have high acuity in the facility, and I need help with that . . .” Staff 1 acknowledged the RN was not regularly scheduled for onsite duties nor had the facility ensured an adequate number of nursing hours relevant to the acuity of the resident population. The need to ensure regularly scheduled licensed nursing hours for onsite duties and an adequate number of nursing hours relevant to the acuity of the resident population was reviewed with Staff 1 (ED) and Staff 2 (RN) during the exit conference on 02/27/26. The findings were acknowledged.

1-The resident health service documentation identified during the survey was immediately reviewed and updated to ensure it accurately reflects the resident’s health status,needs,and services being provided. 2-The facility reviewed health service procedures to ensure resident health information, physician orders, and care needs are properly documented and communicated among staff. •Established a regular RN schedule of a minimum of (16–24)hours per week,adjusted based on resident acuity. •Implemented an on-call RN system to ensure coverage at all times. •Implemented a policy requiring immediate RN notification for any significant change in condition. •RN will complete assessments and review/sign service plans within 48 hours of significant change. •Implemented a tracking log for RN hours, assessments, and service plan reviews. 3-Monthly resident chart audits for three months to ensure health services documentation is complete and current. 4-Executive Director ,RN and RCC

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

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: A. Based on interview and record review, it was determined the facility failed to ensure significant change of condition assessments, which included documented findings, resident status and interventions made as a result of the assessment, were completed by a facility RN, and that the licensed nurse participated on the service planning team or reviewed the service plan within 48 hours, for 1 of 1 sampled resident (#5) reviewed for a significant change of condition. This is a repeat citation. Findings include, but are not limited to: Resident 5 was admitted to the facility in 2024 with diagnoses which included coronary artery disease and urine retention. During the entrance conference on 05/11/26, staff reported the resident had a recent significant decline in health related to a left ankle fracture and increased assistance in care needs, including and the use of a Hoyer lift and two staff for all transfers. Review of Resident 5’s clinical record revealed the following: * Resident 5 was sent to the hospital on 05/04/26 following a recent fall. S/he returned to the facility on 05/06/26 with the diagnosis of a closed left ankle fracture. The fracture and increased ADL care needs constituted a significant change in condition for which an RN assessment which included documented findings, resident status and interventions made as a result of the assessment was required, and that the licensed nurse participated on the service planning team or reviewed the service plan within 48 hours. * Although Staff 3 (RCC) initiated temporary service plans on 05/06/26 related to the fracture and change in ADL care needs, and evaluated the resident and updated the service plan on 05/07/26, there was no evidence the facility RN performed an assessment of the resident’s significant change in condition or that a licensed nurse participated on the service planning team or reviewed the service plan within 48 hours. Additional information was requested on 05/11/26. During an interview on 05/11/26 at 11:35 am, Staff 1 (ED) reviewed the record and was unable to find documentation that an RN assessment had been completed and that the licensed nurse participated on the service planning team or reviewed it within 48 hours. Staff 2 (RN) was unavailable for interview during the revisit survey. The need to ensure RN assessments were completed timely by a facility RN, and that the licensed nurse participated on the service planning team or reviewed the service plan within 48 hours was reviewed during the exit conference on 05/12/26 with Staff 1 (ED). The findings were acknowledged. B. Based on interview and record review, it was determined the facility failed to ensure regularly scheduled licensed nursing for onsite duties and failed to ensure an adequate number of nursing hours relevant to the acuity of the resident population. This is a repeat citation. Findings include, but are not limited to: During the revisit survey, the facility was home to 24 residents. The entrance conference acuity interview was conducted on 05/11/26 with Staff 5 (MT). During the interview, Staff 5 identified multiple residents with heavy care needs. Review of the posted staffing plan indicated “Registered Nurse visits for 16-24 hours per week.” On 05/11/26, the surveyor requested documentation of licensed nurse hours worked from 03/01/26 to 05/10/26. In an interview with Staff 1 on 05/11/26 at 12:00 pm, she stated she was unsure what days or hours Staff 2 (RN) had worked during that time frame. She said she would contact Staff 2. On 05/12/26, Staff 1 said that between 03/01/26 and 05/10/26, Staff 2 worked on one day, 03/13/26. Staff 1 was unsure how many hours Staff 2 worked that day. From 03/01/26 through 05/10/26, the facility RN worked on one day. In an interview with Staff 1 on 05/12/26 at 9:35 am, the discrepancy between posted RN hours and actual hours worked was reviewed. Staff 1 said the facility had just hired another RN that would be starting soon. The need to ensure regularly scheduled licensed nursing hours for onsite duties and an adequate number of nursing hours relevant to the acuity of the resident population was reviewed with Staff 1 (ED) during the exit conference on 05/12/26. The findings were acknowledged.

1. Corrective action for resident/example: Resident #5 was immediately reviewed for significant change of condition related to the left ankle fracture, increased ADL needs, Hoyer lift use, and two-person transfer needs. The facility RN completed/updated the RN significant change assessment, documented resident status, findings, interventions, transfer needs, fall risk/safety measures, pain/skin monitoring, and follow-up needs. The service plan was reviewed/updated to include Hoyer lift transfer with two staff, mobility limitations, toileting/ADL assistance, monitoring for pain/skin integrity, and notification requirements. The RN reviewed/signed the updated service plan. ED/RCC confirmed staff were informed of the updated care needs before providing care. 2. System correction to prevent recurrence: The facility implemented a Significant Change/RN Assessment Tracking System. Any hospital return, fracture, fall with injury, new Hoyer lift/two-person transfer need, hospice admission, pressure injury, uncontrolled pain, acute health change, or major ADL decline will trigger same-day notification to ED/RCC and RN. The ED/RCC will place the resident on the RN Assessment Log and notify the RN immediately. The RN will complete and document an assessment timely and will participate in the service planning team or review/sign the updated service plan within 48 hours when a significant change service plan is completed. ED/RCC will audit the log before the end of each business day. Staff were re-educated on what constitutes a significant change and the requirement to notify ED/RCC/RN immediately. A licensed nurse schedule/log was also implemented to verify regular onsite RN duties and adequate RN hours based on census and acuity. The posted staffing plan will match actual RN coverage. 3. Evaluation frequency: ED/RCC will review the Significant Change/RN Assessment Log daily for 30 days, then weekly for 3 months, then monthly as part of QAPI. RN hours and onsite visit documentation will be reviewed weekly for 3 months and monthly thereafter. Any missed RN assessment, missing RN service plan review, or RN-hour discrepancy will be corrected immediately and documented. 4. Responsible person: Executive Director is responsible for overall compliance. RCC is responsible for daily tracking, staff notification, and service plan follow-up. Facility RN is responsible for completing/documenting RN assessments and reviewing/signing service plans within required timeframes. ED will monitor completion and maintain evidence in the survey-ready binder.

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

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

OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(B) Delegation and Teaching. Delegation and teaching must be provided and documented by a RN in accordance with the Oregon Administrative Rules adopted by the Oregon State Board of Nursing in chapter 851, division 047. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (#4) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to: According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task, and observing the staff demonstrate the task. During the acuity interview on 02/24/26, Resident 4 was identified to be administered insulin injections by non-licensed staff. Resident 4’s MARs, reviewed from 02/01/26 through 02/25/26, revealed the resident received insulin (to treat diabetes) four times a day. The insulin had been given by Staff 4, Staff 5, and Staff 6 (all MTs) on multiple occasions. Review of initial delegation records for Staff 4 (delegated on 10/28/25), Staff 5 (delegated on 10/31/25), and Staff 6 (delegated on 11/28/25) revealed the following: a. There was no documentation by the RN verifying that all requirements from the initial delegation were met. b. There was no documentation the RN addressed questions the resident may have had. c. There was no documented evidence the RN evaluated the frequency the resident should be reassessed based on their assessed baseline and health problems that may impact the resident’s condition related to the delegated nursing procedure, whether the RN previously authorized the same MTs for the same procedure, and the length of time the RN had worked with the MTs. d. The initial delegation for Staff 6 was completed on 11/28/25. The last delegation assessment completed by the RN was on 10/25/25. There was no evidence the RN performed an assessment of the resident at the time Staff 6 was delegated. Review of periodic inspection records for Staff 4 (completed on 01/24/26), Staff 5 (completed on 01/22/26), and Staff 6 (completed on 02/25/26) reveled the following: a. There was no documentation by the RN verifying that all requirements from the delegation were met. b. There was no assessment of the resident. The requirements for delegation were reviewed with Staff 2 (RN) during interviews on 02/27/26. She acknowledged the findings. The need to ensure all staff who administered insulin injections were appropriately delegated in accordance with OSBN Administrative Rules was discussed with Staff 1 (ED) and Staff 2 (RN) during the exit conference on 02/27/26. They acknowledged the findings.

1.The RN reviewed and corrected all delegation records for Staff 4, 5, and 6 to ensure compliance, including required documentation. Resident #4 was reassessed, and a current nursing assessment was completed. Staff were re-trained, and competency was verified through return demonstrations. A reassessment schedule was established. Delegation for Staff 6 was completed following a current assessment. All periodic inspections were updated with proper documentation. 2.A standardized RN delegation process, checklist, and tracking log have been implemented to ensure all required steps are completed and documented. 3.Monthly audits for three months, then quarterly. 4.Executive Director and RN

OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(B) Delegation and Teaching. Delegation and teaching must be provided and documented by a RN in accordance with the Oregon Administrative Rules adopted by the Oregon State Board of Nursing in chapter 851, division 047. This Rule is not met as evidenced by:

OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(B) Delegation and Teaching. Delegation and teaching must be provided and documented by a RN in accordance with the Oregon Administrative Rules adopted by the Oregon State Board of Nursing in chapter 851, division 047. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (#4) who received insulin injections by unlicensed facility staff. This is a repeat citation. Findings include, but are not limited to: According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task, and observing the staff demonstrate the task. During the acuity interview on 05/11/26, Resident 4 was identified to be administered insulin injections by non-licensed staff. Resident 4’s MARs, reviewed from 05/01/26 through 05/10/26, revealed the resident received insulin (to treat diabetes) four times a day. The insulin had been given by Staff 7 (MT) on multiple occasions. Review of delegation records for Staff 7 revealed the following: *The initial delegation was completed by Staff 2 (RN) on 11/03/25. Per the delegation documentation, it expired on 03/01/26; and *According to the OSBN delegation rules, periodic inspection and evaluation must occur prior to the end of the initial authorization period. As of the survey on 05/11/26, no periodic inspection and evaluation had been completed. Staff 2 was not present at the facility during the revisit. During an interview with Staff 1 (ED) on 05/11/26 at 1:55 pm, she reviewed the record and was unable to find periodic inspection and evaluation delegation documentation for Staff 7. The need to ensure all staff who administered insulin injections were appropriately delegated in accordance with OSBN Administrative Rules was discussed with Staff 1 (ED). She acknowledged the findings. On 05/12/26, Staff 1 stated that Staff 2 came in last evening and completed the delegation for Staff 7. A copy of the delegation was given to the surveyor.

1. Corrective action for resident/example: Resident #4’s insulin delegation record for Staff #7 was reviewed. Staff #7’s prior delegation had expired on 03/01/26 and the RN completed updated delegation documentation on 05/12/26. Before any unlicensed staff administer insulin or other special tasks of nursing care, the facility will verify that written RN delegation is current, resident-specific, task-specific, and staff-specific. If delegation is expired or missing, the staff member will not perform the delegated task until the RN completes assessment, teaching, return demonstration/competency validation, written authorization, and required supervision/evaluation. 2. System correction to prevent recurrence: The facility implemented a Delegation Tracking Binder and Delegation Expiration Log for all delegated nursing tasks, including insulin administration. The log will include resident name/identifier, delegated task, staff name, RN name, date delegated, expiration/review date, competency/return demonstration date, and periodic inspection/evaluation due date. ED/RCC will review the log before scheduling staff to perform delegated tasks. Medication technicians and caregivers will be re-educated that they may not perform insulin injections or other special nursing tasks unless current written RN delegation is on file. The RN will complete all delegation, teaching, competency evaluation, return demonstration, and periodic inspection/evaluation according to OSBN Division 47 requirements. A reminder system will be used 30 days before expiration so periodic inspection/evaluation is completed before the delegation expires. 3. Evaluation frequency: ED/RCC will audit the Delegation Expiration Log weekly for 3 months, then monthly as part of QAPI. The RN will review active delegations at least monthly and before any delegation expiration date. Any expired, incomplete, or missing delegation will result in immediate removal of the staff member from that task until RN delegation is completed. 4. Responsible person: Facility RN is responsible for delegation, teaching, competency validation, and periodic inspection/evaluation. RCC is responsible for maintaining the delegation binder/log and checking delegation status before assigning tasks. Executive Director is responsible for monitoring the system and ensuring corrective action is completed.

OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(B) Delegation and Teaching. Delegation and teaching must be provided and documented by a RN in accordance with the Oregon Administrative Rules adopted by the Oregon State Board of Nursing in chapter 851, division 047. This Rule is not met as evidenced by:

OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(B) Delegation and Teaching. Delegation and teaching must be provided and documented by a RN in accordance with the Oregon Administrative Rules adopted by the Oregon State Board of Nursing in chapter 851, division 047. 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 implement effective methods of infection control for 2 of 2 sampled residents (#s 7 and 9) who received care. Findings include, but are not limited to: Observations were made in the facility during the survey to determine adherence to universal precautions for infection control. 1. Resident 9 was admitted to the facility in 02/2023 with diagnoses which included dementia. Observations and interviews with staff during the survey revealed the resident was incontinent, relied on staff for incontinence care needs, and had a pressure wound on his/her bottom. On 09/01/26 at 11:20 am, the surveyor obtained permission and observed Staff 16 and 21 (CGs) provide ADL care to Resident 9. During the observation, both staff donned gloves and assisted the resident with incontinence care. While wearing the same gloves, Staff 16 wiped the resident's perineum, then proceeded to apply barrier cream to the resident's bottom. The surveyor intervened and asked Staff 16 to don clean gloves prior to application of the barrier cream. Per the surveyor's request, Staff 16 donned clean gloves before applying the barrier cream. The above observation was discussed with Staff 1 (ED) on 09/02/26 at 10:10 am. She acknowledged appropriate infection control practices were not implemented. No further information was provided. 2. Resident 7 was admitted to the facility in 09/2022 with diagnoses including multiple sclerosis, functional quadriplegia, and osteoporosis. Resident 7 was dependent on staff for ADL care. On 08/31/26 at 10:32 am, the surveyor obtained permission and Staff 4 (MT) and Staff 17 (CG) were observed to provide care to Resident 7. Staff 4 performed bandage and dressing changes while wearing gloves. During the dressing and bandage changes, Staff 4 identified the resident had a bowel movement and provided assistance, including turning the resident and touching the resident’s linens. Staff 4 handled the resident’s clothing and brief changes, as well as the bandage and dressing changes, using the same gloves. Additionally, Staff 11 wiped the resident’s bottom with wipes, removed the soiled brief, applied a new brief, touched the resident’s linens, and adjusted the resident’s body position while wearing the same pair of gloves. Staff 11 did not change gloves between clean and dirty tasks. Throughout the entire skin care and incontinence care process, both Staff 4 and Staff 11 did not change gloves. The need to ensure infection prevention and control practices were followed during care was discussed with Staff 1 (ED) on 09/02/26 at 9:20 am. The staff acknowledged the findings.

1. Residents 7 and 9: staff involved in care will be re-educated and competency-checked on standard precautions and changing gloves between dirty and clean tasks. Gloves must be removed, hand hygiene performed, and clean gloves applied before moving from incontinence/perineal care to barrier cream, wound/dressing care, clean linens, clothing, or other clean tasks. 2. An infection-control in-service and return-demonstration will be required for direct-care and medication staff. Infection-control expectations will be added to new-hire orientation and care observations. Gloves and hand-hygiene supplies will remain readily available at points of care. 3. RN/LN or designee will observe infection-control technique on all shifts weekly for 4 weeks, then monthly for 3 months. Deficiencies will be corrected at the time observed with documented re-education/competency follow-up. 4. RN/LN will monitor infection-control practice and competencies; ED will ensure training completion and corrective follow-up.

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)(b-d) Systems: Medication Administration (b) Medications administered by the facility must be set-up or poured and documented by the same person who administers the medications.(c) The staff person who administers the medication must visually observe the resident take (e.g., ingest, inhale, apply) the medication unless the prescriber's order for that specific medication states otherwise.(d) Medications must be kept secure between set-up and administration of medications. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure medications were kept secure between set-up and administration of medications for multiple unsampled residents. Findings include, but are not limited to: On 02/25/26 at 12:20 pm, there were several medications found in an unlocked cupboard and refrigerator in Cottage B. The need to ensure medications were kept secure between set-up and administration of medications was discussed with Staff 1 (ED) on 02/25/26 at 1:10 pm. She acknowledged the findings.

1-The medication administration practices identified during the survey were immediately reviewed. Any discrepancies in medication administration or documentation were corrected to ensure medications are administered and documented according to physician orders and facility policy. 2-The facility reviewed its medication administration procedures to ensure medications are: •Administered according to physician orders •Documented accurately on the Medication Administration Record (MAR) •Stored and handled according to facility policy and safety requirements All resident MARs were reviewed to verify accuracy and compliance. 3-Weekly MAR Audits 4- Executive Director, RCC, RN

OAR 411-054-0055 (1)(b-d) Systems: Medication Administration (b) Medications administered by the facility must be set-up or poured and documented by the same person who administers the medications.(c) The staff person who administers the medication must visually observe the resident take (e.g., ingest, inhale, apply) the medication unless the prescriber's order for that specific medication states otherwise.(d) Medications must be kept secure between set-up and administration of medications. 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 orders were carried out as prescribed for 1 of 3 sampled residents (#7) whose orders were reviewed. Findings include, but are not limited to: Resident 7 was admitted to the facility in 09/2022 with diagnoses including multiple sclerosis, functional quadriplegia, and osteoporosis. The resident’s 08/01/26 through 08/31/26 MAR and physician’s orders were reviewed, and staff interviews were conducted during the survey, revealing the following: a. The physician order indicated to administer Baclofen 40 mg (to help relax muscles) at bedtime. The Baclofen had not been transcribed onto the MAR and had not been administered to the resident. b. The physician’s order indicated to administer Lasix (to remove extra water) daily and to hold if the resident’s systolic blood pressure was below 100. The MAR showed the medication was administered to the resident on one occasion when his/her systolic blood pressure was below 100. c. The physician’s order indicated to administer Potassium (supplement) daily and to hold if the resident’s systolic blood pressure was below 100. The MAR showed the medication was administered to the resident on one occasion when his/her systolic blood pressure was below 100. d. The physician order indicated to administer Melatonin 10 mg every evening with dinner for sleep aid. The MAR showed the medication was scheduled to be administered at 11:00 pm, not at dinner time as prescribed. e. The physician order indicated to apply Ketoconazole 2% shampoo three times a week to “scalp/face/neck/ear and leave on 4 minutes then rinse.” The MAR showed the treatment was not applied to the resident on eight occasions, and there was no clear explanation documented for why the treatment was not applied. On 09/02/26 at 9:20 am, the findings were reviewed with Staff 1 (ED). She acknowledged the findings.

1. Resident 7: the RN/LN will reconcile current signed provider orders against the MAR/TAR, including Baclofen, Lasix and Potassium hold parameters, Melatonin administration time, and Ketoconazole treatment. Any discrepancy will be corrected with the pharmacy/provider, and staff will follow the current order exactly. Missed or held medications/treatments will be documented with the reason and required notification/follow-up. 2. A medication-order verification process will require new/changed orders to be compared with the MAR/TAR after transcription and again before implementation. The RN/LN will conduct routine order-to-MAR audits, and medication staff will be trained to stop and clarify any discrepancy, hold parameter, timing instruction, or missing treatment before administration. 3. RN/LN will audit new/changed orders within 24 hours and review MAR/TAR accuracy weekly for 8 weeks, then monthly for 3 months. Medication-pass observations will be completed at least quarterly and additionally when concerns are identified. 4. RN/LN is responsible for clinical order/MAR review and medication oversight; ED will monitor completion of audits and corrective actions.

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 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure MARs were accurate for 1 of 3 sampled residents (#9) whose medications were reviewed. Findings include, but are not limited to: Resident 9 was admitted in 02/2023 with diagnoses which included dementia. Resident 9's MARs were reviewed from 08/01/26 through 09/01/26 and the following was noted: * Reason for use was not indicated for all medications; * Lack of resident-specific instructions for two PRN bowel medications, including sequential order of use; and * The resident had an order for Silver Sulfadiazine cream to be applied topically twice a day. The MAR lacked specific information indicating where the cream was to be applied. Additionally, Staff 5 (MT) initialed on 09/01/26 that she had applied the cream that morning. However, in an interview on 09/01/26 at 11:50 am, she stated the cream was not applied and that the MAR was inaccurate. The need to ensure MARs were accurate and provided clear instructions to unlicensed staff was discussed with Staff 1 (ED) on 09/02/26 at 10:10 am. The findings were acknowledged.

1. Resident 9: the RN/LN will reconcile the MAR with current provider orders. Each medication will include an indication/reason for use as required; PRN bowel medications will have clear resident-specific instructions and sequence of use obtained from the provider; Silver Sulfadiazine directions will identify the specific application site. Staff will document administration only after the medication/treatment is actually provided. 2. The facility will use an order/MAR accuracy checklist for all new and changed orders. PRN orders must include indication and clear parameters/instructions before use. Medication staff will be re-educated that MAR initials are legal documentation and may be entered only after administration. Unclear orders will be held for clarification consistent with provider/pharmacy direction and facility policy. 3. RN/LN will audit new/changed orders within 24 hours and audit MARs weekly for 8 weeks, then monthly for 3 months. Any inaccurate or incomplete entry will be addressed immediately and staff competency reviewed. 4. RN/LN will conduct medication/MAR audits and staff competency follow-up; ED will verify audits and corrective actions are completed.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. 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 and interview, it was determined the facility failed to ensure a restraint free environment for 1 of 1 sampled resident (#9) who was observed with a restraint. Findings include, but are not limited to: Resident 9 was admitted to the facility in 02/2023 with diagnoses which included dementia. Interviews with staff during the survey revealed s/he required full assistance with ADLs, needed two staff to assist with all transfers, and had a history of falls. On 08/31/26 between 10:10 am and 12:15 pm, the resident was seated in a wheelchair with a gait belt around his/her waist and attached around the back of the wheelchair. (Gait belts are strictly designed for temporary, hands-on CG assistance while standing, walking, or transferring and should be removed as soon as the resident is safely seated.) In an interview with Staff 16 (CG) on 08/31/26 at 12:15 pm, she said the family had requested that staff attach the gait belt to the resident’s waist and wheelchair “so [s/he] didn’t fall because [s/he] tries to get up.” The resident was observed in the wheelchair during observations on 09/01/26. No gait belt was used. In an interview with Staff 1 (ED) on 09/02/26 at 10:10 am, she was unaware staff had used the gait belt to secure the resident to the wheelchair. She said she would educate staff to use the gait belt only for mobility assistance.

1. Resident 9: staff will not use a gait belt to secure the resident to a wheelchair. Gait belts will be used only as a temporary hands-on transfer/mobility aid and removed once the transfer is complete. The resident's fall-risk interventions and transfer needs will be reviewed by the RN/LN and reflected in the service plan as appropriate. Staff and family will be informed that a restraint cannot be used for convenience or fall prevention unless specifically permitted by rule and all required criteria are met. 2. All direct-care staff will receive training on restraints and proper gait-belt use. The facility will review residents who use mobility devices to identify any device/practice with restraining qualities and ensure service plans and care instructions are compliant. Gait-belt expectations will be included in orientation and transfer competency checks. 3. ED/RN designee will observe transfer and wheelchair practices on all shifts weekly for 4 weeks, then monthly for 3 months. Any restraint concern will be stopped immediately and investigated with retraining as indicated. 4. Executive Director and RN/LN. The ED will ensure restraint-free practices; RN/LN will review transfer needs and service-plan interventions.

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

OAR 411-054-0070 (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 4 of 4 sampled direct care staff (#s 6, 7, 8, and 9) demonstrated satisfactory performance in any duty they were assigned within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed with Staff 1 (ED) on 02/26/26 at 10:33 am. There was no documented evidence Staff 6 (MT), hired on 11/10/25, Staff 7 (MT), hired on 11/03/25, Staff 8 (CG), hired on 11/22/25, and Staff 9 (CG), hired on 01/06/26, had demonstrated competency in one or more of the following areas: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting changes of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety and sanitation; and * First Aid/Abdominal Thrust. The need to ensure newly hired direct care staff had demonstrated satisfactory performance in all required areas within 30 days of hire was reviewed with Staff 1 (ED) on 02/26/26 at 10:33 am. She acknowledged the findings.

1-The staff training records identified during the survey were immediately reviewed. Any staff member whose required training was incomplete or not documented within the required timeframe had the training completed and documentation updated in the employee file. 2-All employee files were reviewed to ensure required orientation and training are completed within 30 days of hire in accordance with state requirements. A tracking system has been implemented to monitor staff training deadlines and ensure all required training is completed timely. 3-Review employee training records monthly for three months to ensure all new staff complete required training within the required timeframe. Ongoing monitoring will continue during routine personnel file audits. 4- Executive director and Office Manager

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 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to: Refer to C0280, C0282, and C0513.

1. Corrective action for resident/example: The facility reviewed the revisit findings related to the prior relicensure plan of correction and identified areas requiring stronger implementation: RN significant change assessments/service plan review (C280), RN delegation/teaching supervision (C282), and environmental cleanliness/repair/odor control (C513). Immediate corrective actions were initiated for each cited area, including RN assessment/service plan tracking, delegation tracking, and Cottage B environmental repair/cleaning/odor remediation. 2. System correction to prevent recurrence: The facility implemented a POC Compliance Monitoring Binder to track each citation, action item, responsible person, completion date, proof of completion, and ongoing audit results. The ED will conduct a weekly POC review meeting with RCC, RN, maintenance/housekeeping lead, and/or designee until sustained compliance is demonstrated. Each prior POC item will remain on the tracking log until evidence shows implementation is complete and ongoing monitoring is occurring. The ED will verify that policies, logs, staff education, RN documentation, delegation records, and environmental repairs match the plan of correction and are available for review. 3. Evaluation frequency: POC items will be evaluated weekly through 06/26/26 and weekly for 3 additional months, then monthly during QAPI. Any item found incomplete will be corrected immediately, assigned to a responsible person, and rechecked within 24-72 hours depending on the issue. 4. Responsible person: Executive Director is responsible for ensuring the POC is implemented, monitored, and sustained. RCC, Facility RN, and Maintenance/Housekeeping Lead are responsible for completing and documenting assigned corrective actions. ED will maintain the compliance binder and report progress through QAPI.

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 revisit survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to: Refer to C513.

1. The facility will correct and maintain the environmental deficiencies identified under C0513, including cleaning floors, walls, furniture, rug, sliding-door area and patio; removing stored/scattered items; replacing the missing transition strip; and repairing/replacing water-damaged baseboard and other damaged surfaces. Corrections will be verified before alleging compliance. 2. A written environmental cleaning/maintenance system will assign daily housekeeping tasks and weekly environmental rounds. Deficiencies will be entered on a maintenance/cleaning log with an assigned person and completion date. Repeat items will be escalated to the ED until verified complete. 3. Environmental rounds will be completed weekly for 8 weeks, then monthly for 3 months, with daily housekeeping checks of high use/common areas. The ED will verify completion and document follow-up. 4. Executive Director, with designated housekeeping/maintenance staff responsible for assigned corrections and documentation.

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 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on interview and observation, it was determined the facility failed to ensure the grounds were kept orderly and free of litter and refuse, were free from drop-offs, and locked storage was provided for all toxic materials. Findings include, but are not limited to: The facility was toured with Staff 1 (ED) on 02/25/26 at 1:10 pm. The following was noted: * On 02/24/26 at 10:45 am, Oxivir TB disinfectant and Windex cleaner were noted to be unsecured in the common restroom of Cottage A. * On 02/25/26 at 10:03 am, a bottle of bleach was noted in an unsecured cupboard in the laundry room of Cottage B and multiple spray bottles filled with various toxic chemicals were noted in the laundry room of Cottage A. * On 02/25/26 at approximately 12:40 pm, there was refuse noted along the back corner patio and upper portion of the pathway on the side of Cottage B. * On 02/24/26, drop-offs exceeding one inch were noted along the exterior pathways of both Cottages A and B. The need to ensure the grounds were kept orderly and free of litter and refuse, were free from drop-offs that exceeded one inch, and there was locked storage for all toxic materials was discussed with Staff 1 (ED) on 02/25/26 at 1:10 pm. She acknowledged the findings.

1-The exterior condition identified during the survey was immediately addressed. The area noted by the surveyor was inspected and repairs or cleaning were completed to ensure the exterior of the building is safe, well maintained, and free from hazards. 2-The facility conducted a full inspection of the building exterior, including walkways, entrances, outdoor areas, and surrounding grounds, to ensure all areas are maintained in a safe and clean condition. Any maintenance needs identified during this inspection were corrected. 3-Monthly Exterior safety inspection 4- Executive Director and Maintenance

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by:

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure lever-type handles were provided on all doors used by residents and the facility was kept clean and in good repair and was free from unpleasant odors. Findings include, but are not limited to: The facility was toured with Staff 1 (ED) on 02/25/26 at 1:10 pm. The following was noted: * The lever-type door handle on the entrance to Cottage B was not functioning properly and several door handles in Cottage B were in disrepair; * Scuffs, chipped paint, and gouges were noted on doors, door frames, furniture, cupboards, and handrails throughout both Cottages A and B, making some surfaces uncleanable. The door seal around apartments 7, 9, and 14 was loose; * An unpleasant and pervasive odor was noted throughout the survey in the upper level and staircase in Cottage B; * There was debris and dust noted on baseboards and windowsills throughout Cottages A and B and on the ventilation screen near the main sink on the lower level of Cottage B; * Furniture throughout the interior and exterior of both Cottages A and B was dirty, stained, moldy, or in disrepair; * Food and fluid drips were noted on cupboards, microwave, and refrigerator in the kitchenette of Cottage B; and * The tile flooring in the kitchenette in Cottage B was cracked in places, creating an uncleanable surface. The need to ensure that lever-type handles were provided on all doors used by residents and the facility was kept clean, in good repair, and free from unpleasant odors was discussed with Staff 1 (ED) on 02/25/26 at 1:10 pm. She acknowledged the findings.

1-The areas identified during the survey were inspected and corrected. Doors, walls, and interior areas were cleaned and repaired as needed, and any odors identified were addressed through cleaning and ventilation to ensure a clean and comfortable environment for residents 2-The facility reviewed housekeeping and maintenance procedures to ensure the interior of the building is maintained in a clean, sanitary, and odor-free condition. Routine cleaning and maintenance schedules were reinforced to ensure doors, walls, and common areas are regularly inspected and maintained. 3-Weekly Environmental rounds and followed by monthly inspections 4-Executive Director and Maintenance

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by:

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure lever-type handles were provided on all doors used by residents and the facility was kept clean and in good repair and was free from unpleasant odors. This is a repeat citation. Findings include, but are not limited to: The facility was toured with Staff 1 (ED) on 05/12/26 at 9:00 am. The following was noted: * The lever-type door handle on the entrance to Cottage B was not functioning properly; * Pervasive odor was noted throughout the survey in the upper level in Cottage B; * There was debris and dust noted on some baseboards and windowsills throughout Cottage B; * Food and fluid drips were noted on cupboards, the microwave, and refrigerator in the kitchenette of Cottage B; and * The tile flooring in the kitchenette in Cottage B was cracked in places, creating an uncleanable surface. The need to ensure that lever-type handles were provided on all doors used by residents and the facility was kept clean, in good repair, and free from odors was discussed with Staff 1 (ED) on 05/12/26 at 9:00 am during the environment walk through, and again at 11:30 am. She acknowledged the findings.

1. Corrective action for resident/example: Cottage B entrance lever-type door handle was inspected and repaired/replaced to ensure it functions properly for resident use. Cottage B was deep cleaned, including baseboards, windowsills, cupboards, microwave, refrigerator, and kitchenette surfaces. The upper-level odor concern was addressed through immediate cleaning, trash/soiled-linen removal, carpet/floor cleaning as applicable, ventilation, and review for possible source of odor. The cracked kitchenette tile flooring was evaluated and repaired/replaced or covered with an approved cleanable repair until permanent repair is completed, to maintain a cleanable surface. 2. System correction to prevent recurrence: The facility implemented a Cottage B Environmental Rounds Log and Cleaning/Maintenance Tracking System. Housekeeping staff will complete daily cleaning of high-touch and food-service areas, including the kitchenette, microwave, refrigerator exterior/interior as assigned, cupboards, baseboards, and windowsills. Staff will report odors, broken handles, cracked flooring, or uncleanable surfaces immediately to ED/RCC or maintenance. Maintenance will complete weekly environmental rounds for door hardware, flooring, walls, ceilings, furniture, odors, and repair needs. ED/RCC will verify that resident-use doors have functioning lever handles and that interior/exterior surfaces remain clean, odor-free, and in good repair. Staff were re-educated on reporting environmental concerns immediately and documenting completion of cleaning/maintenance tasks. 3. Evaluation frequency: Housekeeping/odor checks will be completed daily for 30 days, then weekly. Maintenance rounds will be completed weekly for 3 months, then monthly. ED/RCC will audit Cottage B weekly for 3 months and monthly through QAPI. Any odor, cleanliness concern, broken lever handle, or damaged flooring will be corrected promptly and documented on the maintenance log. 4. Responsible person: Executive Director is responsible for overall environmental compliance. Maintenance/designee is responsible for repairs, door hardware, flooring, and maintenance rounds. Housekeeping Lead/designee is responsible for daily cleaning and odor control. RCC/ED will monitor completion of logs and verify sustained correction.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean and in good repair. This is a repeat citation. Findings include, but are not limited to: Observation of the facility on 08/31/26 showed the following areas in Building B needed to be cleaned and/or repaired: * The floors throughout, particularly along the edges, had marks, accumulated dust, and gaps between the baseboards and the floor; * The wall near the kitchenette had multiple black marks and dried food debris; * Multiple couches on the second floor had black and reddish-colored stains; * Items including blinds and baseboards were stored on the second floor balcony; * The transition strip was missing in the first floor kitchenette area; * On the first floor, the baseboard beneath the kitchenette cabinet had evidence of water damage; * The rug on the first floor had stains and multiple layers of accumulated dust; * The sliding door to access the back patio had accumulated dust and spider webs along the door frame; and * The back patio had various items scattered throughout, including tissues, dirty cushions, plastic beverage containers, wood, cigarette butts, plastic spoons, and other silverware. On 09/02/26 at 11:02 am, the above areas were toured with Staff 1 (ED), who acknowledged the findings. The need to maintain the interior and exterior of the facility, furniture, and surfaces clean and in good repair was discussed with Staff 1 on 09/02/26 at 11:30 am during the exit. The staff acknowledged the findings.

1. Building B will be cleaned and repaired in all cited areas: floors/edges and gaps will be cleaned and addressed; kitchenette wall debris/marks removed; stained couches cleaned or replaced; balcony storage removed; missing transition strip installed; water-damaged baseboard repaired/replaced; first-floor rug deep-cleaned or replaced; sliding-door frame cleaned of dust/webs; and the back patio cleared and cleaned of litter, cigarette butts, dirty cushions, containers, wood and utensils. 2. The facility will implement a preventive environmental-rounding checklist covering floors, walls, baseboards, furniture, rugs, doors/windows, balconies, patio and repair needs. Housekeeping and maintenance concerns will be logged, assigned, dated, and verified by the ED. Staff will report new damage, spills, stains, clutter, or sanitation concerns promptly rather than waiting for scheduled rounds. 3. Housekeeping will check common areas daily. ED/designee will conduct documented environmental rounds weekly for 8 weeks, then monthly for 3 months. Unresolved repair items will remain on the log until the ED verifies completion. 4. Executive Director will monitor the system; designated housekeeping and maintenance staff will complete assigned cleaning and repairs.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by:

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. 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 and dignity for 2 of 2 sampled residents (#s 4 and 9) and a homelike environment for multiple unsampled residents. Findings include, but are not limited to: Refer to C 200.

Refer to C200

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. This Rule is not met as evidenced by:

OAR411-004-0020(1)(d) Individual Rights Settings Right to Freedom (1) Residential and non-residential HCB settings must have all of the following qualities: (d) The setting ensures the individual the right to freedom from restraints, except in accordance with the standards set forth in ORS 443.739, OAR chapters 309 and 411, 1915(c) HCBS Waivers, 1915(i) State Plan HCBS, or 1915(k) Community First Choice (K State Plan Option). When the right to freedom from restraints must be limited due to a threat to the health and safety of an individual or others, an individually-based limitation as described in OAR 411-004-0040 must apply in any residential or non-residential setting. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure individuals had the right to freedom from restraints for 1 of 1 sampled resident (#9). Findings include, but are not limited to the following: Refer to C 340.

Refer to C0340

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

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (c) Each resident record must, before move-in and when updated, include the following information: (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name (B) Pronouns. (C) Gender identity. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure initial evaluations addressed all required elements, including the preferred name, pronouns, and gender identity for 1 of 1 sampled resident (#3) whose evaluation was reviewed. Findings include, but are not limited to: Refer to C 252.

Refer to C252

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (c) Each resident record must, before move-in and when updated, include the following information: (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name (B) Pronouns. (C) Gender identity. This Rule is not met as evidenced by: