OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of residents. Findings include, but are not limited to: The facility was a memory care community which was home to 21 residents who were all diagnosed with some type of dementia and who experienced various degrees of cognitive decline and confusion. During a tour of the facility on 03/10/26 at 12:25 pm, multiple closets and storage rooms were found to be unlocked, and they contained potentially dangerous materials or objects as follows: * A closet where art supplies were stored (near room 2) contained a container of scissors; * A utility closet across from the beauty shop contained two bottles of liquid laundry detergent and boxes of powdered laundry detergent; and * A bank of wooden built-in cabinets near the med room contained a pair of surgical scissors and a variety of chemical medical supplies (mouthwash, antiseptics, etc.). The unsecured materials and scissors represented conditions that could threaten the health, safety, or welfare of residents. The need to exercise reasonable precautions by securing potentially dangerous items was discussed with Staff 1 (Administrator) on 03/10/26 at 1:40 pm. She acknowledged the unsecured areas.

Upon identification of the concern, all chemicals, sharp objects, and hazardous items were immediately removed from unsecured areas and placed in locked cabinets in designated staff areas, and all resident-accessible areas were inspected to ensure no harmful items were accessible. The facility has implemented a policy requiring that all chemicals and sharp objects be always secured in locked cabinets or areas inaccessible to residents, and staff are responsible for identifying and properly securing any potentially hazardous items immediately after use. All staff, including caregivers and med passers, will be educated on this policy and safety expectations by 05/10/26, and this training will be included in new employee orientation. The Administrator/Resident Care Manager (RCM) is responsible for ensuring ongoing compliance, and this plan will be fully implemented by 05/10/26.

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of residents. This is a repeat citation. Findings include, but are not limited to: The facility was a memory care community which was home to 19 residents who were all diagnosed with some type of dementia and who experienced various degrees of cognitive decline and confusion. During a tour of the facility on 06/16/26 at 11:14 am, multiple doors, cabinets, and storage rooms were found to be unlocked. They contained potentially dangerous materials or objects as follows: * A drawer of the curio cabinet in the dining room contained a pair of scissors. * The resident accessible courtyard included a box of plant fertilizer and a spray bottle of insecticide. * The cabinet near room nine had a can of disinfectant spray and two small bottles of essential oils. * The door labeled “Laundry Room” led to a hallway which included an unsecured industrial cleaning supplies storage room, the industrial laundry room, and an elevator. * The unsecured beauty shop contained a hot glue gun with a glue stick located on the countertop. Cabinets within the shop included a spray bottle of fabric refresher, multiple household cleaners, an unlabeled clear fluid in a spray bottle, a spray disinfectant, and nail clippers; and * A bank of wooden built-in cabinets in the television room contained a spray bottle of fabric refresher. The unsecured materials, areas, and scissors represented conditions that could threaten the health, safety, or welfare of residents. The need to exercise reasonable precautions by securing potentially dangerous items and areas was discussed with Staff 3 (RCM/Designee) on 06/16/26 at 11:55 am, and again with Staff 3 and Staff 2 (RN) on 06/17/26 at 3:56 pm. They acknowledged the findings. The areas remained secured through all observations on 06/17/26.

Upon identification of the concern, the facility revised its Sharps and Hazardous Materials Safety Policy to require that all chemicals and sharp objects be secured in locked cabinets or other areas inaccessible to residents immediately after use. Staff are responsible for identifying and properly securing any potentially hazardous items. A daily environmental safety walkthrough checklist will be completed by caregivers to monitor compliance. All staff, including caregivers and medication aides, will receive education on the revised policy and safe storage of hazardous materials. This education will also be incorporated into new employee orientation. The Administrator and Resident Care Manager (RCM) are responsible for monitoring ongoing compliance through daily environmental safety checks.

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by:

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the initial resident evaluation contained all required elements, was dated, and indicated who was involved in the evaluation process, for 1 of 1 sampled resident (#1) whose move-in evaluation was reviewed. Findings include, but are not limited to: Resident 1 was admitted to the facility in 10/2025 with diagnoses including dementia. The facility provided three documents that it used to gather information about a new resident: a seven-page evaluation titled “Rock of Ages Memory Care Facility,” the “OR/WA: Initial and Annual Licensed Nursing Assessment,” and the facility “Personal Interest Questionnaire.” The following was identified: a. None of the documents indicated who was involved in the evaluation process, and only the nursing assessment included a date. b. The evaluations failed to address the following elements: * Name, pronouns, and gender identity; * Customary routines regarding eating and bathing; * Traditions; * Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; * How the person copes with change or challenging situations; * Ability to manage medications; * Housework and laundry; * Transportation; * Emergency evacuation ability; * Complex medication regimen; * History of dehydration; * Recent losses; * Unsuccessful prior placements; and * Elopement risk or history. The need to ensure the initial evaluation contained information addressing all required elements was reviewed with Staff 1 (Administrator) and Staff 2 (RN) on 03/11/26 at 11:00 am. They acknowledged the information that was lacking.

Following the survey finding, the facility conducted a review of current resident move-in evaluations and updated them to include all required elements, including residents’ routine meals, frequency of ADL assistance, personal traditions, date of last physician visit, frequency of medical follow-ups, and coping mechanisms for stress, ensuring all assessments include a signature and date. The move-in evaluation packet has been revised to include these elements, and a process has been implemented to ensure all assessments and care plans are completed prior to move-in; for emergency placements, assessments and care plans will be completed within 24 hours of admission. The Administrator, Memory Care Nurse, and Resident Care Manager (RCM) is responsible for oversight, and this plan will be fully implemented by 05/10/26.

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the initial resident evaluation contained all required elements for 1 of 1 sampled resident (#4) whose move-in evaluation was reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 4 was admitted to the facility in 05/2026 with diagnoses including Alzheimer’s disease. Resident 4’s 05/14/26 move-in evaluation was reviewed. The document failed to address the following required elements: * Pronouns and gender identity; * Customary routines regarding eating; * Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; * Dental status; * Ability to use a call system; * Skin condition; * Fall risk or history; * Complex medication regimen; * Unexplained weight loss or gain; * Smoking; * Alcohol and drug use; and * Environmental factors that impact the resident’s behavior including, but not limited to lighting and room temperature. The need to ensure the initial evaluation contained information addressing all required elements was reviewed with Staff 3 (RCM/Designee) and Staff 2 (RN) on 06/17/26 at 3:39 pm. They acknowledged the findings.

Following the survey finding, the facility reviewed and revised the Pre-Admission Assessment & Resident Preference Profile, and RN Assessment to ensure all required elements are included, including the resident’s gender identity and preferred pronouns. The move-in evaluation packet has been updated to include all required assessment components, and a process has been implemented to ensure all required assessments and care plans are completed prior to resident move-in. Resident 4’s move-in evaluation was reviewed and updated to include all required assessment elements. The resident’s service plan was revised as needed based on the completed evaluation.The Administrator, Memory Care RN, and Resident Care Manager will review all new move-in evaluations within 72 hours of admission to ensure they are complete. Compliance will be monitored monthly for three months, and thereafter through routine admission record audits.

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

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents’ current care needs and provided clear direction to staff, for 1 of 3 sampled residents (#3) whose service plans were reviewed. Findings include, but are not limited to: Resident 3 was admitted to the MCC in 08/2021, with diagnoses including dementia, hypertension, and osteoporosis. Review of Resident 3's service plan, dated 01/06/26, and temporary care plans, observations of the resident, and interviews with staff revealed the service plan was not reflective or lacked clear direction to staff in the following areas: * Use of side rails on the resident’s bed; * Hospice services received; and * History of suicidal ideations and behaviors Observations during the survey confirmed Resident 3 had 1/2 rails on both sides of the bed. Hospice visit notes were reviewed in the resident’s clinical record, confirming Resident 3 was receiving hospice services. An RN assessment, dated 01/29/26, included the statement, “[Resident 3] requires close supervision and ongoing monitoring to help prevent and respond to suicidal thoughts, verbalizations, and behaviors.” These concerns were verified by Staff 2 (RN) in an interview on 03/11/26 at 1:05 pm. On 03/12/26 at 12:45 pm, the need to ensure service plans were reflective of current resident care needs and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 3 (Resident Care Manager). They acknowledged the findings.

In response to the cited deficiency, the facility conducted a review of current resident service plans to ensure they accurately reflect individual needs, including hydration and eating preferences with intake amounts, past and current activity interests, and behaviors including identified stressors and appropriate coping interventions, and updates were made as needed. The move-in evaluation packet and service plan process have been revised to include these required elements and to ensure that all identified needs are consistently reflected in the service plan. The Administrator, and Resident Care Manager (RCM) are responsible for oversight and ongoing compliance, and this plan will be fully implemented by 05/10/26.

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 determine, document, and communicate to staff what actions or interventions were needed for the resident following a change of condition, ensure weekly progress was noted until the condition was resolved, and monitor each resident consistent with his or her evaluated needs and service plan, for 1 of 1 sampled resident (#3) who experienced multiple falls. Findings include, but are not limited to: Resident 3 was admitted to the MCC in 08/2021, with diagnoses including dementia, hypertension, and osteoporosis. Review of Resident 3’s clinical record revealed the following: a. The resident experienced four documented falls between 12/10/25 and 03/10/26. Following each fall, the facility failed to determine and document what actions or interventions were needed for the resident, communicate the interventions to staff, and note weekly progress until the condition was resolved. b. The service plan listed the following interventions for fall prevention: * Encourage [him/her] to use walker; * Keep light on in the bathroom at night; * Make sure [he/she] is wearing sandals or older gray shoes; and * Use alarm in bed and in wheelchair. There was no documented evidence the facility monitored the fall interventions following each fall to determine if the interventions were effective or if new interventions needed to be developed. On 03/11/26 at 1:05 pm, Staff 2 (RN) was interviewed regarding Resident 3’s falls. Staff 2 acknowledged the facility did not identify interventions, monitor the resident’s progress, or monitor the service-planned fall interventions for effectiveness following each fall. On 03/12/26 at 12:45 pm, the need to determine, document, and communicate to staff what actions or interventions were needed for the resident following a change of condition, ensure weekly progress was noted until the condition was resolved, and monitor the resident’s fall interventions for effectiveness was discussed with Staff 1 (Administrator) and Staff 3 (Resident Care Manager). They acknowledged the findings.

Following the survey finding, the facility reviewed recent fall and incident records to ensure appropriate monitoring and documentation were completed. The facility has implemented a policy and checklist for falls, incidents, and return from ER to ensure a consistent process that includes completion of an initial incident report, initiation of alert charting and monitoring, and a final progress note indicating resolution and evaluation of interventions for effectiveness. The process also includes implementation and review of fall interventions to determine if they are effective and require revision. All staff will be educated on these requirements by 05/10/26, including expectations for timely documentation, ongoing monitoring, and follow-up after incidents, and this will be included in new employee orientation. The Administrator, Nurse, Resident Care Manager (RCM) are responsible for oversight and ongoing compliance, and this plan will be fully implemented by 05/10/26.

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 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to conduct fire drills according to the Oregon Fire Code (OFC), keep a complete written fire drill record, and provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to: Review of fire and life safety records, dated 10/2025 through 03/2026, revealed the following: a. Two of three fire drill records did not indicate whether residents were evacuated or relocated during fire drills. In an interview on 03/11/26 at 10:50 am, Staff 5 (Chief Operations Officer) acknowledged residents were not being relocated during fire drills. b. Fire drill records lacked consistent documentation of the following components: * Escape route used; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Evacuation time period needed; and * Number of occupants evacuated. c. Fire and life safety training was not being provided to staff on alternate months, as required. In an interview on 03/12/26 at 12:45 pm, the need to include residents in fire drills, keep a complete written fire drill record, and provide fire and life safety instruction to staff on alternate months was discussed with Staff 1 (Administrator) and Staff 3 (Resident Care Manager). They acknowledged the findings.

1. Fire drill roster forms have been updated to include all required documentation. Fire and life safety drill schedules have been updated to include alternating months of training and fire drills. 2. All staff who conduct fire drills have been in serviced on what documentation is required when conducting a drill. 3. A monthly audit will be conducted to ensure the training or drill has been completed. 4. The COO is responsible for ensuring compliance

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

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview, it was determined the facility failed to instruct residents within 24 hours of admission and re-instruct residents, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. Findings include, but are not limited to: In an interview on 03/11/26 at 10:50 am, Staff 5 (Chief Operations Officer) stated the facility had not been providing instruction to residents on fire and life safety topics at admission and re-instruction annually. No records were provided. There was no documented evidence residents received fire and life safety instruction within 24 hours of admission, and were reinstructed at least annually, thereafter. On 03/12/26 at 12:45 pm, the need to provide and document fire and life safety instruction for residents within 24 hours of admission and at least annually thereafter was discussed with Staff 1 (Administrator) and Staff 3 (Resident Care Manager). They acknowledged the findings.

In response to the cited deficiency, the facility conducted a review of current residents to ensure fire and life safety instructions were provided and documented, and any missing education was completed. The facility has implemented a process to provide fire and life safety instructions to all residents upon admission and annually thereafter, with documentation maintained in the resident's record. A tracking system has been established to ensure annual education is completed in a timely manner for each resident. The Administrator will conduct monthly audits of resident records to ensure compliance with admission and annual training requirements. The Administrator is responsible for oversight and ongoing compliance, and this plan will be fully implemented by 05/10/26.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to instruct residents within 24 hours of admission in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This is a repeat citation. Findings include, but are not limited to: In an interview on 06/16/26 at 2:00 pm, Staff 5 (Chief Operations Officer) stated the facility had established a system to provide fire and life safety training to residents within 24 hours of admission. Proof of training upon admission was requested for Resident 4, who moved into the MCC in 05/2026. On 06/17/26 at 12:16 pm, Staff 2 (RCM/Designee) reported the training for Resident 4 was not completed, because the facility had not finished creating and implementing the new system. There was no documented evidence residents received fire and life safety instruction within 24 hours of admission. On 06/17/26 at 3:54 pm, the need to provide and document fire and life safety instruction for residents within 24 hours of admission was discussed with Staff 3 (RCM/Designee) and Staff 2 (RN). They acknowledged the findings.

In response to the cited deficiency, the facility implemented a Resident Orientation Record as part of the admission packet. The form includes documentation of the resident’s safety orientation, including fire and life safety instructions, emergency procedures, and general facility orientation to ensure all required education is provided and documented. Any missing orientation for current residents has been completed and documented. The Administrator or RCM will review each new resident admission packet within 24 hours of admission to verify the Resident Orientation Record has been completed and filed in the resident's records. Compliance will be audited monthly for three months and then incorporated into routine quality assurance reviews.

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

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to: Refer to: C160, C252, C422, Z142, Z162, and L252.

Refer to the Plans of Correction for C160, C422, C252, Z142, Z162, and L252. The Administrator and Resident Care Manager (RCM) will provide ongoing oversight to ensure continued compliance.

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 (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 all interior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) were kept clean and in good repair. Findings include, but are not limited to: The facility was toured on 03/10/26 at 12:25 pm. The following was identified: * There were corners of the baseboard in the hallways that were gouged, exposing bare wood; * Doors and doorframes of resident rooms 3, 4, 5, 8, and 16 were scraped, exposing bare wood; and * There was a large brown spot/stain on the carpet in front of the courtyard entry door on the front side of the unit (near the TV/fireplace common area). The areas needing cleaning and repair were toured with Staff 1 (Administrator) on 03/10/26 at 1:40 pm. She acknowledged the areas needing cleaning and repair.

In response to the cited deficiency, the facility addressed environmental concerns by cleaning-stained carpets, painting wooden door frames and doors, and repairing dents in walls to ensure all areas are in good condition. The facility has implemented a routine maintenance and housekeeping process to ensure carpets, doors, and surrounding areas are maintained in good repair and free from damage or excessive wear. The Administrator will conduct monthly environmental rounds to ensure ongoing compliance, with any identified issues addressed promptly. The Administrator is responsible for oversight and ongoing compliance, and this plan will be fully implemented by 05/10/26.

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 (5) Resident Units (5) RESIDENT UNITS. Resident units may be limited to a bedroom only, with bathroom facilities centrally located off common corridors. Each resident unit shall be limited to not more than two residents.(a) Resident units must have a lockable door with lever type handles, effective 01/15/2017. This applies to all existing and new construction.(b) For bedroom units, the door must open to an indoor, temperature controlled common-use area or common corridor. Residents may not enter a room through another resident's bedroom.(c) Resident units must include a minimum of 80 square feet per resident, exclusive of closets, vestibules, and bathroom facilities and allow for a minimum of three feet between beds;(d) All resident bedrooms must be accessible for individuals with disabilities and meet the requirements of the building codes. Adaptable units are not acceptable.(e) A lockable storage space (e.g., drawer, cabinet, or closet) must be provided for the safekeeping of a resident's small valuable items and funds. Both the administrator and resident may have keys.(f) WARDROBE CLOSET. A separate wardrobe closet must be provided for each resident's clothing and personal belongings. Resident wardrobe and storage space must total a minimum volume of 64 cubic feet for each resident. The rod must be adjustable for height or fixed for reach ranges per building codes. In calculating useable space closet height may not exceed eight feet and a depth of two feet.(g) WINDOWS.(A) Each sleeping and living unit must have an exterior window that has an area at least one-tenth of the floor area of the room. A CF must have at least one exterior window with a minimum size of 8 square feet per resident.(B) Unit windows must be equipped with curtains or blinds for privacy and control of sunlight.(C) Operable windows must be designed to prevent accidental falls when sill heights are lower than 36 inches and above the first floor.(h) RESIDENT UNIT BATHROOMS. If resident bathrooms are provided within a resident unit, the bathroom must be a separate room and include a toilet, hand wash sink, mirror, towel bar, and storage for toiletry items. The bathrooms must be accessible for individuals who use wheelchairs.(i) UNIT KITCHENS. If cooking facilities are provided in resident units, cooking appliances must be readily removable or disconnect-able and the RCF must have and carry out a written safety policy regarding resident-use and nonuse. A microwave is considered a cooking appliance. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to provide a lockable storage space (e.g., drawer, cabinet, or closet) in each resident unit for the safekeeping of a resident's small valuable items and funds. Findings include, but are not limited to: During an interview and a tour of his/her apartment on 03/11/26 at 2:40 pm, Resident 1 reported the apartment did not have a lockable storage space. The surveyor did not observe a lockable storage space in Resident 1’s apartment. In an interview on 03/11/26 at 2:50 pm, Staff 1 (Administrator) confirmed none of the resident units had a lockable storage space. The need to provide a lockable storage space in each resident unit was reviewed with Staff 1, Staff 2 (RN), Staff 3 (Resident Care Manager), and Staff 5 (Chief Operations Officer) on 03/12/26 at 1:50 pm. They acknowledged the findings.

Following the survey finding, the facility ensured that each resident apartment is equipped with functional lockable storage by placing lockboxes in all resident rooms and verifying that each unit has appropriate lockable storage available. The facility has implemented a process to ensure all new admissions are provided with lockable storage upon move-in, and that lockboxes remain functional and in good condition. The Administrator is responsible for oversight and ongoing compliance, and this plan will be fully implemented by 05/10/26.

OAR 411-054-0200 (5) Resident Units (5) RESIDENT UNITS. Resident units may be limited to a bedroom only, with bathroom facilities centrally located off common corridors. Each resident unit shall be limited to not more than two residents.(a) Resident units must have a lockable door with lever type handles, effective 01/15/2017. This applies to all existing and new construction.(b) For bedroom units, the door must open to an indoor, temperature controlled common-use area or common corridor. Residents may not enter a room through another resident's bedroom.(c) Resident units must include a minimum of 80 square feet per resident, exclusive of closets, vestibules, and bathroom facilities and allow for a minimum of three feet between beds;(d) All resident bedrooms must be accessible for individuals with disabilities and meet the requirements of the building codes. Adaptable units are not acceptable.(e) A lockable storage space (e.g., drawer, cabinet, or closet) must be provided for the safekeeping of a resident's small valuable items and funds. Both the administrator and resident may have keys.(f) WARDROBE CLOSET. A separate wardrobe closet must be provided for each resident's clothing and personal belongings. Resident wardrobe and storage space must total a minimum volume of 64 cubic feet for each resident. The rod must be adjustable for height or fixed for reach ranges per building codes. In calculating useable space closet height may not exceed eight feet and a depth of two feet.(g) WINDOWS.(A) Each sleeping and living unit must have an exterior window that has an area at least one-tenth of the floor area of the room. A CF must have at least one exterior window with a minimum size of 8 square feet per resident.(B) Unit windows must be equipped with curtains or blinds for privacy and control of sunlight.(C) Operable windows must be designed to prevent accidental falls when sill heights are lower than 36 inches and above the first floor.(h) RESIDENT UNIT BATHROOMS. If resident bathrooms are provided within a resident unit, the bathroom must be a separate room and include a toilet, hand wash sink, mirror, towel bar, and storage for toiletry items. The bathrooms must be accessible for individuals who use wheelchairs.(i) UNIT KITCHENS. If cooking facilities are provided in resident units, cooking appliances must be readily removable or disconnect-able and the RCF must have and carry out a written safety policy regarding resident-use and nonuse. A microwave is considered a cooking appliance. This Rule is not met as evidenced by:

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to provide a call system that connected resident units to the care staff center or staff pagers and failed to provide a manually operated emergency call system in each toilet and bathing facility used by residents and visitors. Findings include, but are not limited to: The facility was toured on 03/10/26 at 12:25 pm. The following was identified: a. During an interview and a tour of Resident 1’s apartment, no call system was observed in the resident’s bathroom or living space. When asked how s/he would call for assistance when in the unit, Resident 1 stated s/he did not know. In an interview on 03/11/26 at 2:50 pm, Staff 1 (Administrator) stated the facility provided each resident with a call pendant that connected to the facility’s call system and staff pagers. During the survey, from 03/10/26 through 03/12/26, residents were not observed wearing pendants. In an interview on 03/12/26 at 11:24 am, Staff 9 (CG) acknowledged that, though residents were provided call pendants, most did not wear them either because they preferred not to and kept removing them, or the resident’s pendant was misplaced somewhere in the resident’s apartment. The observations and interview with the CG were shared with Staff 1 on 03/12/26 at 11:40 am. She acknowledged the facility needed to ensure residents wore their pendants. b. Two common-use bathroom/spa rooms did not have a manually operated emergency call system. In an interview on 03/11/26 at 2:50 pm, Staff 1 acknowledged the two common bathrooms did not have a manually operated emergency call system. The need to ensure the facility had a call system that connected resident units to the care staff center or staff pagers and a manually operated emergency call system in each toilet and bathing facility used by residents and visitors was reviewed with Staff 1, Staff 2 (RN), Staff 3 (Resident Care Manager), and Staff 5 (Chief Operations Officer) on 03/12/26 at 1:50 pm. They acknowledged the findings.

The facility has identified the need to upgrade the current call light system and is in the process of coordinating with vendors for installation of a new system. In the interim, to ensure resident safety and timely response to needs, staff are ensuring residents are wearing their call pendants; for residents who choose not to wear them or are unable to do so, staff are providing increased monitoring through frequent checks. The Administrator will oversee this process and ensure continued compliance until the new system is implemented

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by: Based on an interview at 10:05 am on 06/16/26 with Staff 3 (RCM/Designee), it was confirmed the facility had received an extension for the allegation of compliance until 08/17/26.

An extension was granted for correction of this deficiency. The facility has coordinated with the contracted vendor for installation of the iAlert call system, which is scheduled for July 16 and July 17, 2026. The Chief Operating Officer (COO) is responsible for overseeing completion of the installation. Upon completion, the facility will verify the system is fully operational and provide any necessary staff education on its use.

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by:

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure resident units had entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. Findings include, but are not limited to: During an interview and a tour of his/her apartment on 03/11/26 at 2:40 pm, Resident 1 reported s/he did not have a key to the unit. S/he said it seemed odd that s/he was not given a key to their apartment and had “wondered about that.” In an interview on 03/11/26 at 2:50 pm, Staff 1 (Administrator) stated residents were not given a key to their unit unless they asked for one. The facility failed to provide each resident with a key to their unit as required. The need to ensure residents were provided a key to their unit was reviewed with Staff 1, Staff 2 (RN), Staff 3 (Resident Care Manager), and Staff 5 (Chief Operations Officer) on 03/12/26 at 1:50 pm. They acknowledged the findings.

In response to the cited deficiency, the facility verified that all current residents have been offered and provided a key to their apartment, and this was documented, with any missing keys issued immediately. The facility has implemented a process to ensure each resident is provided a key at move-in in accordance with resident rights, and this will be documented in the move-in process. Residents who choose not to carry or use their key may keep it in their apartment per their preference. The Administrator is responsible for oversight and ongoing compliance, and this plan will be fully implemented by 05/10/26.

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. 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 the move-in evaluation addressed all required elements, including name, pronouns, and gender identity, for 1 of 1 sampled resident (#1) whose move-in evaluation was reviewed. Findings include, but are not limited to: Refer to C 252.

N/A

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 the move-in evaluation addressed all required elements, including pronouns and gender identity for 1 of 1 sampled resident (#4) whose move-in evaluation was reviewed. This is a repeat citation. Findings include, but are not limited to: Refer to: C252.

Following the survey finding, the facility reviewed and revised the Pre-Admission Assessment & Resident Preference Profile, and RN Assessment to ensure all required elements are included, including documentation of each resident’s gender identity and preferred pronouns. The move-in evaluation packet has been updated to ensure all required assessments and care plans are completed prior to move-in, and that required resident information is accurately documented. The Administrator, Memory Care Nurse, and Resident Care Manager (RCM) are responsible for monitoring compliance with the revised move-in process.

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:

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C160, C420, C422, C513, C515, C555, and H1518.

This deficiency is related to Tags C160, C420, C422, C513, C515, and C555, and the corrective actions outlined under those tags will address the concerns identified. Interim measures have been implemented, including ensuring residents are wearing call pendants. Staff have been educated on safety expectations. The Administrator/ Resident Care Manager (RCM) will monitor compliance through routine safety audits to ensure sustained compliance.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to: C160 and C422.

In response to the cited deficiency, the facility has implemented administrative oversight to ensure ongoing compliance with the corrective actions identified under C160 and C422. Policies, procedures, staff education, and monitoring processes have been revised to ensure hazardous materials and sharp objects are properly secured and that resident fire and life safety orientation is provided and documented upon admission in accordance with facility policy and regulatory requirements. The Administrator and Resident Care Manager (RCM) are responsible for monitoring compliance through routine audits and ongoing staff education.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by:

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C252, C260, and C270.

This deficiency is related to Tags C252, C260, and C270, and the corrective actions outlined under those tags will address the concerns identified. Staff have been educated on requirements for assessments, service plans, and post-incident monitoring. The Administrator/Resident Care Manager (RCM) will monitor compliance through routine record audits to ensure sustained compliance.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to: C252.

In response to the cited deficiency, the facility has implemented administrative oversight to ensure ongoing compliance with the corrective actions identified under C252. The Pre-Admission Assessment & Resident Preference Profile, and RN Assessment have been revised to include all required elements, and a process has been implemented to ensure all required assessments and care plans are completed prior to resident move-in. The Administrator, Memory Care Nurse, and Resident Care Manager (RCM) are responsible for monitoring compliance through routine audits of move-in documentation, and ongoing oversight.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: