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 move-in evaluations addressed all required elements and failed to address sufficient information to develop the initial service plan to meet the resident's needs for 1 of 1 sampled resident (# 1) whose move-in evaluation was reviewed. Findings include, but are not limited to: Resident 1 moved into the facility in 03/2026 with diagnoses including multiple sclerosis, paraplegia, and anxiety. The move-in evaluation, which included documentation from the resident's prior facility, was reviewed. The following required elements were not addressed: * Spiritual, cultural preferences and traditions; * Fluid preferences; * Complex medication regimen; * Recent losses; * Preferred pronouns; and * Gender identity. There was documented evidence the facility had information relating to the following elements, however the information had not been utilized to develop Resident 1's initial service plan to meet his/her needs: * Mental health issues including the presence of depression, thought disorders or behavioral or mood problems, the history of treatment, and effective non-drug interventions; * Personality including how the person copes with change or challenging situations; * Ability to be understood; * Dental status; and * Nutrition habits. During an interview on 03/30/26 at 1:33 pm, Staff 14 (CG) confirmed the resident exhibited behaviors pertaining to his/her care and meals. She stated Resident 1 spoke in a quiet tone which made it difficult to understand what the resident needed. Staff 14 reported that when care staff did not understand what Resident 1 needed, it was also a behavioral trigger for the resident. On 04/01/26 at 11:01 am, Staff 1 (Administrator) and Staff 2 (Director of Nursing) explained that they used multiple documents from the previous facility for their initial evaluation. There was no documented evidence the additional documentation provided was used to develop Resident 1's initial service plan. The need to ensure move-in evaluations addressed all required elements and was used to develop an initial service plan to meet the resident's needs was discussed with Staff 1, Staff 2, Staff 3 (Facility RN), Staff 4 (RCC), and Staff 5 (RCC in training) on 04/01/26 at 11:01 am. No additional information was received.

1. Immediate correction: Resident #1’s move-in evaluation was fully updated to include all required elements including spiritual/cultural preferences, fluid preferences, complex medication regimen, recent losses, preferred pronouns, and gender identity. All previously available information (mental health, coping, communication, dental, nutrition) was incorporated into the service plan and reviewed and co-signed by the RN. 2. A comprehensive move-in evaluation checklist has been developed that mirrors all required elements under OAR 411-054-0034, including: spiritual/cultural preferences; fluid preferences; complex medication regimen; recent losses; preferred pronouns; gender identity; mental health history; personality/coping; communication abilities; dental status; and nutrition habits. This checklist will incorporated onto the facility's electronic health record (EHR) system as a required prompt that must be completed prior to finalizing any move-in evaluation. A corresponding paper sign-off form has also been implemented, confirming all elements have been addressed and that all available information has been incorporated into the resident's initial service plan. Staff have been educated on the updated process and the requirement that all elements must be documented — and if information is unavailable, a specific notation of "unable to obtain at this time" must be entered with a plan for follow-up within the initial 30-day period. 3. The RCC will audit all new move-in evaluations within 24 hours of completion to verify all required elements are present. The Facility Nurse will conduct a monthly review of any move-in evaluations completed during that month to ensure ongoing compliance. Additionally, all move-in evaluations will be reviewed at the quarterly service plan update to confirm required elements remain current and that any changes in condition have been incorporated. Any significant change of condition will trigger an immediate evaluation review. 4. The Resident Care Coordinator (RCC) is the primary person responsible for completing and auditing move-in evaluations at the time of admission. The Facility Nurse is responsible for reviewing and co-signing all completed move-in evaluations to verify compliance with all required elements. The Administrator is responsible for overseeing the overall process and will review audit results monthly.

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 provided clear direction regarding the delivery of services for 3 of 3 sampled residents (#s 1, 2, and 3) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 12/2025 with diagnoses including vascular dementia and functional quadriplegia. A review of the 03/08/26 service plan and progress notes, dated 03/03/26 through 03/30/26, identified the service plan was not reflective of the resident's current care needs and did not provide clear direction regarding the delivery of services in the following areas: * Continence of bladder; * Assistance required with toileting, activities, bathing, and use of glasses; * Behaviors exhibited and monitoring; * Number of staff required to assist during evacuation, with wheelchair mobility, and dressing; * Individual who was assisting with financial management; * Risks and precautions related to the use of bilateral side rails; * Ability to use call system and type of device used; * Direction regarding Foley catheter care, including emptying/cleaning catheter bag; and * Use of alternating pressure mattress, right wrist splint, and roll placed in left hand. Observations on 03/30/26 through 04/01/26 revealed the resident had bilateral half-length side rails placed in a raised position, an alternating pressure mattress, a touch pad call switch, a right wrist splint, and a roll placed for positioning in the left hand while awake. During an interview on 03/30/26 at 10:30 am, Resident 3 stated s/he did not use the side rails for mobility because his/her hands could not grab onto them. However, s/he confirmed the use of the right wrist splint and the roll placed in the left hand while awake. During an interview on 03/31/26 at 10:42 am, Staff 4 (RCC) acknowledged much of the conflicting information was that the resident had previously lived at the facility and was much more independent at that time. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (Director of Nursing), Staff 3 (Facility RN), Staff 4, and Staff 5 (RCC in training) on 04/01/26 at 10:55 am. They acknowledged the findings. 2. Resident 2 moved into the facility in 03/2023 with diagnoses including heart failure and diabetes. A review of the 03/08/26 service plan and progress notes, dated 01/01/26 through 03/30/26, identified the service plan was not reflective of the resident’s needs and did not provide clear direction regarding the delivery of services in the following area: * Risks and precautions related to the use of bilateral half-length side rails. During an observation and interview with Resident 2 on 03/31/26 at 10:30 am, bilateral half-length side rails were observed on the resident’s bed in the raised position. The need to ensure residents’ service plans were reflective of residents’ needs and provided clear direction to staff regarding the delivery of services was reviewed with Staff 1(Administrator), Staff 2 (Director of Nursing), Staff 3 (Facility RN), Staff 4 (RCC), and Staff 5 (RCC in training) on 04/01/26 at 12:05 pm. They acknowledged the findings. 3. Resident 1 moved into the facility in 03/2026 with diagnoses including multiple sclerosis, paraplegia, and anxiety. A review of the 03/03/26 service plan and progress notes, dated 03/03/26 through 03/30/26, identified the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas: * Risks and precautions related to the use of bilateral siderails; * Behaviors including triggers and interventions; * Amount of assistance the resident required with snacks; * Personal seasoning assistance on meals; and * Detailed directions on transfers and positioning. During an interview on 03/30/26 at 1:33 pm, Staff 14 (CG) confirmed the resident exhibited behaviors, could independently eat “chips” if she opened the bag, had personal seasoning for CGs to add to the resident’s food, and wanted “things specific” relating to transfers and repositioning. During an observation and interview with Resident 1 on 03/30/26 at 1:47 pm, bilateral half-length siderails were observed on the resident’s bed, in the raised position. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (Director of Nursing), Staff 3 (Facility RN), Staff 4 (RCC), and Staff 5 (RCC in training) on 04/01/26 at 11:01 am. They acknowledged the findings.

1.Immediate action for cited residents: The Resident Care Coordinator (RCC) reviewed and updated the service plans for Residents 1, 2, and 3 to reflect all current care needs identified during the survey. Updates in progress include: bilateral side rail risks and precautions for all three residents; Foley catheter care instructions including emptying and cleaning the catheter bag; documentation of assistive devices in use including the alternating pressure mattress, right wrist splint, touch pad call switch, and hand roll (Resident 3); behavior triggers, interventions, and monitoring protocols; number of staff required to assist with evacuation, wheelchair mobility, and dressing; required assistance levels for toileting, bathing, activities, and use of glasses; snack assistance and personal seasoning instructions (Resident 1); and detailed transfer and repositioning directions (Resident 1). Each corrected service plan is reviewed and co-signed by the Facility RN to confirm accuracy and completeness before implementation. All updates are dated and initialed per OAR requirements. 2. A service plan review checklist has been developed and integrated into the pre-admission, move-in, 30-day review, and quarterly review processes to ensure all care elements are captured and clearly communicated to direct care staff. The checklist requires explicit documentation of: all assistive devices in use and associated care instructions; required number of staff for all assisted activities; risk and precaution statements for any restrictive devices including side rails; behavioral triggers, interventions, and monitoring frequency; and individualized directions for transfers, repositioning, and ADL assistance. The facility's ABST care elements are updated concurrently with each service plan revision. Service plans are reviewed in PointClickCare and verified to align with observed care practices prior to finalization. 3. Service plans will be reviewed and updated pre-admission, upon move-in, at the 30-day review, quarterly in conjunction with the resident evaluation and ABST update, and immediately upon any significant change of condition. The RCC reviews and updates service plans at each required interval. The Facility RN co-signs each completed service plan update to verify clinical accuracy. The Administrator conducts a spot-check audit of service plans monthly to ensure ongoing compliance and that care directions are current and clearly written for direct care staff. 4. The Resident Care Coordinator (RCC) is the primary person responsible for completing and updating service plans at all required intervals. The Facility RN is responsible for reviewing and co-signing each service plan update. The Administrator is responsible for monthly spot-check audits and overall accountability for service plan compliance across the facility.

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 medication and treatment orders were carried out as prescribed for 2 of 3 sampled residents (#s 2 and 3) who were administered medications and treatments. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 03/2023 with diagnoses including heart failure and diabetes. The resident’s practitioner orders, dated 03/04/26, and MAR, dated 03/01/26 to 03/30/26, were reviewed, and the following was identified: The resident had orders for insulin degludec pen, 64 units once a day between 4:00 pm and bedtime. The MAR was blank on 03/13/26 and 03/24/26. In an interview on 03/31/26 at 11:40 am, Staff 2 (Director of Nursing) could not verify the insulin had been administered as ordered on 03/13/26 or 03/24/26. The need to ensure the facility carried out medication orders as prescribed was reviewed with Staff 1 (Administrator), Staff 2, Staff 3 (Facility RN), Staff 4 (RCC), and Staff 5 (RCC in training) on 04/01/26 at 12:05 pm. They acknowledged the findings. 2. Resident 3 moved into the facility in 12/2025 with diagnoses including vascular dementia and functional quadriplegia. The resident’s practitioner orders, signed 03/18/26, and MAR, dated 03/01/26 to 03/30/26, were reviewed, and the following was identified: a. The resident had a 01/07/26 order for barrier cream to buttocks twice daily and as needed, following cleaning skin after brief changes. The MAR was blank on three occasions. b. The resident had a 01/07/26 order for positioning for pressure injury prevention. The MAR was blank on one occasion. The order was discontinued on 03/17/26. Additionally, the resident had a 03/17/26 order for positioning every two hours, use of disposable pads, and barrier cream application each brief change. The MAR was blank on two occasions. c. The resident had a 02/26/26 order for positioning every three hours, use of disposable pads, and barrier cream application after each brief change. The MAR was blank on seven occasions, and the order was discontinued on 03/17/26. In an interview on 03/31/26 at 10:45 am, Staff 2 (Director of Nursing) stated that the treatment documentation was “a work in progress” and acknowledged the inability to determine if the barrier cream administration, brief change, and positioning had occurred when the MAR was blank. The need to ensure the facility carried out medication orders as prescribed was reviewed with Staff 1 (Administrator), Staff 2, Staff 3 (Facility RN), Staff 4 (RCC), and Staff 5 (RCC in training) on 04/01/26 at 10:55 am. They acknowledged the findings.

1. Immediate action for cited residents: A root cause review was conducted for all cited MAR blanks. It was determined that the omissions were documentation errors — care and treatments were provided by staff but were not signed off at the time of administration. The Facility RN reviewed and addressed the documentation gap for both Resident 2 and Resident 3, with progress notes written to account for the omissions and the identified root cause. Staff responsible for the unsigned entries were individually counseled regarding the requirement to sign the MAR at the time of administration or prior to the next resident-specific medication or treatment, per OAR 411-054-0055(2)(a). All current MAR entries for Residents 2 and 3 have been reviewed and verified to be complete and accurate. 2. The RCCs conduct MAR audits every Monday and Thursday to identify any unsigned, blank, or incomplete entries. Upon identifying an omission, the RCC immediately addresses the responsible MT/CG to determine whether care was provided and to document accordingly. The Facility RN conducts a quarterly 90 day med list review of all active practitioner orders to verify that orders are current, clearly written, and being carried out as prescribed. Staff have been re-educated on the requirement to sign the MAR at the time medications or treatments are administered and that blank entries are not acceptable regardless of whether care was provided and thus reviewed by MTs before shift end. Any MAR blank identified during an audit that cannot be explained is escalated to the Facility RN for clinical review and documentation within the same business day. 3. MAR audits are conducted by the RCC a minimum of twice weekly with additional random audits performed by the RCC and Administrator as needed. The Facility RN reviews all practitioner orders at a minimum quarterly and for any significant changes. Any identified omission or documentation concern is addressed immediately. Monthly, the Administrator reviews audit findings as part of the facility's quality improvement process. 4. The Resident Care Coordinators (RCCs) are responsible for twice-weekly MAR audits and immediate follow-up on any identified omissions. The Facility RN is responsible for quarterly order reviews and clinical escalation of any unresolved MAR concerns. The Administrator is responsible for monthly review of audit outcomes and overall accountability for medication and treatment documentation compliance.

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 an accurate MAR was kept of all medications administered by the facility, and MARs included resident-specific parameters and instructions for PRN medications for 3 of 3 sampled residents (#s 1, 2, and 3) whose records were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 03/2023 with diagnoses including heart failure and diabetes. The resident’s MAR, dated 03/01/26 to 03/30/26, and corresponding prescriber orders were reviewed, and the following was identified: a. The resident had orders for insulin degludec pen, 64 units once a day between 4:00 pm and bedtime. The MAR was blank on 03/19/26. In an interview on 03/31/26 at 10:45 am, Staff 2 (Director of Nursing) confirmed the MT had not documented the resident’s refusal of the medication on 03/19/26, and it had not been administered. b. The following PRN bowel medications lacked the sequential order for administration: * MiraLax oral packet 17 GM; and * Senna 8.6 mg tablet. The need to ensure the resident’s MAR was accurate and included resident-specific parameters for PRN medications used for the same diagnosis was discussed with Staff 1 (Administrator), Staff 2, Staff 3 (Facility RN), Staff 4 (RCC), and Staff 5 (RCC in training) on 04/01/26 at 12:05 pm. They acknowledged the findings. 2. Resident 3 moved into the facility in 12/2025 with diagnoses including vascular dementia and functional quadriplegia. The resident’s MAR, dated 03/01/26 to 03/30/26, and corresponding prescriber orders were reviewed, and the following was identified: The following PRN bowel medications lacked sequential order for administration: * Polyethylene glycol 3350, 17 grams; and * Senexon-S 50-8.6 mg tablet. During an interview on 03/31/26 at 10:40 am, Staff 4 (RCC) confirmed the lack of resident-specific parameters. The need to ensure the MAR was accurate and included resident-specific parameters for PRN medications used for the same diagnosis was discussed with Staff 1(Administrator), Staff 2 (Director of Nursing), Staff 3 (Facility RN), Staff 4, and Staff 5 (RCC in training) on 04/01/26 at 10:55 am. They acknowledged the findings. 3. Resident 1 moved into the facility in 03/2026 with diagnoses including multiple sclerosis, paraplegia, and anxiety. The resident’s MAR, dated 03/01/26 to 03/30/26, and corresponding prescriber orders were reviewed. The following was identified: a. Resident 1 had orders for a PRN bisacodyl suppository (for constipation) that had not been transcribed onto the MAR. b. The following PRN bowel medications lacked the sequential order for administration: * Enema; * Milk of Magnesia; * Polyethylene glycol powder; and * Senna. On 03/30/26 at 12:45 pm, Staff 11 (MT/CG) was able to review the electronic MAR and verified the parameters were not listed in the system. The need to ensure the resident’s MAR was accurate and included resident-specific parameters for PRN medications used for the same diagnosis was discussed with Staff 1 (Administrator), Staff 2 (Director of Nursing), Staff 3 (Facility RN), Staff 4 (RCC), and Staff 5 (RCC in training) on 04/01/26 at 11:01 am. They acknowledged the findings.

1. Immediate actions taken: All medication orders for all residents were reviewed by the Facility RN and RCCs to ensure each order contains complete and accurate information including medication name, route, dosage, date, time, and diagnosis or indication. For any order missing a diagnosis or indication, the prescribing practitioner was contacted and the order was updated per their instructions. Resident allergies and sensitivities have been reviewed and updated in each resident's medication profile. Parameters for holding blood pressure medications and insulin have been reviewed and clarified in the MAR. For all PRN bowel medications across all residents, the sequential order of administration has been written into the MAR designating which medication is the first intervention and the order in which subsequent medications are to be used for constipation management. Resident 1's PRN bisacodyl suppository has d/c by provider. Resident 2's medication refusal documentation process has been reviewed with the responsible MT, and the requirement to document refusals in real time has been reinforced. 2. A MAR accuracy checklist has been implemented for use during the RCC's twice-weekly audits. The checklist verifies: all PRN medications have resident-specific parameters and sequential instructions when multiple PRN medications exist for the same diagnosis; all new orders are transcribed completely and accurately onto the MAR within 24 hours of receipt; medication refusals are documented on the MAR at the time of occurrence; and all required MAR fields (medication, route, dosage, date, time, indication, allergies) are present and accurate. The Facility RN reviews all new orders to verify completeness. Staff have been re-educated that documentation of a refusal is required in real time and that omitting this documentation is a MAR accuracy violation. 3. MAR accuracy is evaluated by the RCC a minimum of twice weekly (Monday and Thursday audits), with random additional audits performed by the RCC, Facility RN and Administrator. The Facility RN conducts weekly audits and quarterly comprehensive order and MAR review and review of new orders. Quarterly, the Administrator reviews cumulative audit findings as part of quality improvement oversight. 4. The Resident Care Coordinators (RCCs) are primarily responsible for twice-weekly MAR audits and immediate correction of any identified inaccuracies. The Facility RN is responsible for weekly audits and quarterly comprehensive reviews and clinical oversight of MAR accuracy. The Administrator is responsible for quarterly quality improvement review and overall accountability for MAR compliance across all residents.

OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications were evaluated at least quarterly to assure ability to safely self-administer medications for 1 of 1 sampled resident (# 4) who was reviewed for self-administration of medications. Findings include, but are not limited to: Resident 4 moved into the facility in 10/2024 with diagnoses including type 2 diabetes and asthma. The resident’s clinical record, including “Medication Self-Administration Evaluations,” were reviewed. The following was identified: Resident 4’s 03/01/26 through 03/30/26 MAR reflected an insulin glargine order with the directions to inject 10 units every morning for type 2 diabetes. The additional directions instructed staff that the resident “can self-administer this medication.” A PRN albuterol inhaler (for asthma) was also listed on the MAR. Resident 4’s 03/01/26 through 03/30/26 TAR reflected the resident self-administered Nystatin powder (for rash), four times a day. The treatment was started on 11/24/25. The most recent “Medication Self-Administration Evaluation” was dated 11/06/25. The evaluation was for the insulin and the Albuterol. There was no documented evidence of an evaluation completed for the self-administration of the Nystatin powder. On 03/30/26 at 2:07 pm, Staff 11 (MT/CG) confirmed Resident 4 injected his/her own insulin and stated that the resident “may have an inhaler and some Nystatin in [his/her] room.” Staff 11 confirmed that she did not administer the Nystatin powder. On 04/01/26 at 11:01 am, Staff 2 (Director of Nursing) confirmed the “Medication Self-Administration Evaluation” had not been completed at least quarterly and there was no evaluation completed for the Nystatin powder. The need to ensure residents who chose to self-administer their medications were evaluated at least quarterly, to assure ability to safely self-administer medications, was reviewed with Staff 1 (Administrator), Staff 2, Staff 3 (Facility RN), Staff 4 (RCC), and Staff 5 (RCC in training) on 04/01/26 at 11:01 am. They acknowledged the findings.

1. Immediate actions taken: A self-administration evaluation for Resident 4 has been completed by the Facility RN to address all medications the resident currently self-administers, including insulin glargine, albuterol inhaler, and Nystatin powder. A practitioner order has been obtained authorizing self-administration for each applicable medication per OAR 411-054-0055(5)(b). A facility-wide audit of all residents who self-administer any prescription or treatment medication has been initiated. There are more than five residents who self-administer medications. For each identified resident, the Facility RN is completing an initial or updated self-administration evaluation to ensure all self-administered medications are covered and that evaluations are current. Any resident whose evaluation is overdue or missing is being prioritized for immediate completion. 2. Going forward, the self-administration evaluation process has been restructured as follows: The Facility RN completes all new and initial self-administration evaluations at the time a resident begins self-administering any medication, including any new medication added to an existing self-administration regimen. The RCC completes the quarterly re-evaluation for each self-administering resident, tied directly to that resident's quarterly service plan review date, so that no evaluation is separated from the broader care review cycle. Each evaluation is reviewed and co-signed by the Facility RN. A tracking log of all self-administering residents and their evaluation due dates is maintained by the RCC and reviewed at each quarterly service plan meeting. Any new admission who self-administers medications triggers an immediate self-administration evaluation prior to or at move-in. 3. Self-administration evaluations are completed quarterly, tied to each resident's quarterly service plan review date. The RCC reviews the tracking log at each quarterly service plan meeting to confirm evaluations are current for all self-administering residents. The Facility RN reviews and co-signs all evaluations. The Administrator reviews the tracking log monthly as part of overall medication management oversight. Any new self-administered medication added between quarterly reviews triggers an immediate evaluation by the Facility RN. 4. The Facility RN is responsible for completing all new and initial self-administration evaluations. The Resident Care Coordinator (RCC) is responsible for completing quarterly re-evaluations, maintaining the self-administration tracking log, and ensuring evaluations are completed on schedule in conjunction with the quarterly service plan review. The Administrator is responsible for monthly oversight of the tracking log and overall accountability for self-administration evaluation compliance.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure a sufficient number of direct care staff were present at all times to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: On 03/30/26 the acuity interview identified the following: * The facility was home to 27 residents; * Twenty-one residents were served by a specific needs contract (SNC); * Six residents were not served by the SNC; and * The facility had three separate buildings - A, B, and C. On 03/30/26 the “ABST [acuity-based staffing tool] Facility Entrance Questionnaire” was provided to the facility and was returned on 03/31/26. The following was noted: * The facility had three shifts – day shift was from 7:00 am to 3:00 pm, evening shift was from 3:00 pm to 11:00 pm, and night shift was from 11:00 pm to 7:00 am; and * Day shift had eight direct care staff on duty, evening shift had eight direct care staff on duty, and night shift had six direct care staff on duty. On 03/30/26 at 10:50 am, the “Facility Section Details” were reviewed on the ABST. The following was noted: * “Specific Needs Beds” required up to 29.58 hours of care during the night shift; and * “Regular Beds” required up to 1.5 hours of care during the night shift. The SNC contract was reviewed and specified, “There shall always be no less than [two] direct care staff in each building” for the 21 residents covered under the contract. Per the facility’s staffing plan, there were only two direct care staff members working in each building during the night shift, which did not account for the time needed relating to the six residents whom the facility referred to as “Regular Beds.” The need to ensure a sufficient number of direct care staff were present at all times to meet the 24-hour scheduled and unscheduled needs of each resident was reviewed with Staff 1 (Administrator), Staff 2 (Director of Nursing), Staff 3 (Facility RN), Staff 4 (RCC), and Staff 5 (RCC in training) on 04/01/26 at 11:01 am. They acknowledged the findings.

1.Immediate action: The facility has reviewed the night shift staffing plan for all three buildings (A, B, and C) and adjusted direct care staffing during the night shift to account for the care time required for all 27 residents to ensure the scheduled and unscheduled needs of all residents — both Specific Needs Contract (SNC) and Regular Bed — can be met without compromising care. The facility reviewed and clarified SNC staffing requirements with SNC Policy Administrator and facility has passed 90-day compliance review. The ABST continues to be updated to reflect the current acuity and care time requirements of all residents across all three buildings, and the posted staffing plan has been revised accordingly. 2. The facility's staffing planning process ensures all residents included in staffing calculations. Two separate ABST reports are maintained: one for residents served under the SNC and one for residents classified as Regular Beds. The posted staffing plan for each shift reflects the combined staffing requirements from both ABST reports, inclusive of unscheduled care time needs. Resident Care Coordinator (RCC) manages daily schedule and reviews staffing every shift to ensure adequate staffing in accordance with staffing plan and communicates any staffing issues with Administrator as needed. Staff have been educated on staffing plan. 3. The Administrator and RCC (Scheduler) will conduct a bi-weekly review of the posted staffing plan and actual staffing levels against ABST-calculated requirements for all shifts. The ABST will be reviewed and updated no less than quarterly in conjunction with each resident's quarterly service plan update. The ABST will also be reviewed and updated following any significant change of condition and at the time of each new admission to ensure staffing levels remain sufficient for the changing acuity of the resident population. 4. The RCC is responsible for staff schedules and ongoing monitoring of staffing levels and ensuring the posted staffing plan is current and accurately reflects ABST requirements. The Director of Nursing is responsible for communicating significant changes of condition and new admissions that may require ABST updates. The Administrator holds final accountability for ensuring the facility is staffed in compliance with OAR 411-054-0070(1) at all times.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) was updated no less than quarterly at the same time the resident’s service plan for 2 of 3 sampled residents (#s 2 and 3) whose ABST evaluations were reviewed. Findings include, but are not limited to: Review of clinical records, including service plans for Residents 2 and 3, revealed the facility's ABST was not updated quarterly at the same time as the resident’s service plan in order to ensure the ABST accurately determined the needed staffing level. On 04/01/26 at 11:01 am, the need to ensure the ABST was updated at least quarterly was discussed with Staff 1 (Administrator), Staff 2 (Director of Nursing), Staff 3 (Facility RN), Staff 4 (RCC), and Staff 5 (RCC in training). They acknowledged the findings.

1. Immediate action for cited residents: The RCCs are actively reviewing and updating the ABST evaluations for Residents 2 and 3 concurrently with the service plan corrections currently in progress. Updates to the ABST are being made to reflect each resident's current acuity, care needs, and level of assistance required, ensuring the ABST accurately determines the staffing level needed for each resident. ABST updates for all remaining residents are being reviewed to identify and correct any that are not current. 2. A process document has been updated to require that the ABST is completed or updated at the same time as each resident's service plan at every required interval. The ABST update is now a required step within the service plan review workflow - the RCC cannot finalize a service plan without concurrently updating the ABST in the facility's system. For facilities with both SNC and non-SNC residents, two separate ABST reports are maintained as required: one for residents served under the Specific Needs Contract and one for residents not served by the Contract. The posted staffing plan is reviewed and updated following each ABST update to ensure staffing levels reflect the combined acuity requirements of all residents. Per OAR 411-054-0037(6)(b), if ABST analysis indicates staffing numbers higher than the Contract minimum, the facility staffs to the numbers indicated by the ABST. 3. The ABST is updated no less than quarterly concurrent with each resident's service plan review, upon any significant change of condition, before a new resident's move-in, and whenever the resident population changes in a way that affects overall acuity. The RCC reviews all ABSTs at each quarterly service plan cycle. The Administrator reviews the posted staffing plan monthly to verify it aligns with current ABST outputs and that actual staffing meets or exceeds the plan. 4. The Resident Care Coordinators (RCCs) are responsible for updating the ABST concurrently with each service plan review and ensuring ABST updates are completed at all required intervals. The Administrator is responsible for monthly review of the posted staffing plan against ABST outputs, and for overall accountability for ABST accuracy and compliance. The Facility Nurse is responsible for communicating significant changes of condition that require an out-of-cycle ABST update.

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 4 newly hired direct care staff (#s 7, 12, and 15) had documented evidence of training in the use of abdominal thrust and first aid within 30 days of hire. Findings include, but are not limited to: On 03/31/26, staff training records were reviewed with Staff 4 (RCC) and Staff 5 (RCC in training) and revealed Staff 12 (MT/CG) and Staff 15 (CG), each hired on 02/17/26, lacked documented evidence they had completed first aid certification and abdominal thrust training within 30 days of hire. Staff 7 (MT/CG), hired 11/28/25, had documentation of completion of first aid certification and abdominal thrust on 02/21/26, more than 30 days after hire. The need for staff to complete all required training in the specified time frames was discussed on 04/01/26 at 10:55 am with Staff 1 (Administrator), Staff 2 (Director of Nursing), Staff 3 (Facility RN), Staff 4 and Staff 5. The findings were acknowledged.

1. Immediate actions for cited staff: Staff 7, 12, and 15 are in the process of completing first aid and abdominal thrust training. Documentation of completed training will be placed in each staff member's personnel file upon completion. In addition to addressing the cited training gap, the facility has initiated a comprehensive retraining program for all current direct care staff that includes, but is not limited to: abdominal thrust and first aid; caregiving skills and ADL assistance; medication administration; and all required online training modules. Retraining documentation is being collected and filed for each staff member. 2. A 30-day new hire training checklist has been implemented that lists all required competencies under OAR 411-054-0070(5), including abdominal thrust and first aid, caregiving, ADL assistance, changes associated with aging, condition recognition and reporting, general food safety, and medication and treatment administration competency demonstration where applicable. The RCC assigns the checklist to each new hire on their first day and is responsible for tracking completion. A master staff training calendar has been created that lists each employee, their hire date, required training items, due dates, and completion dates. This calendar is reviewed monthly by the RCC and quarterly by the Administrator to ensure no training deadlines are missed. A new hire cannot be scheduled to work independently with residents until all required 30-day training items are documented as complete and signed off by the appropriate supervisor. 3. The 30-day new hire training checklist is reviewed by the RCC at the time of hire and monitored throughout the 30-day window, with a check-in at day 14 to identify any incomplete items. The master training calendar is reviewed monthly by the RCC and quarterly by the Administrator. Ongoing training requirements for all current staff are tracked on the same calendar and reviewed at each monthly and quarterly cycle to ensure no deadlines are missed. 4. The Resident Care Coordinator (RCC) is the primary person responsible for assigning the 30-day training checklist to new hires, monitoring training completion throughout the 30-day window, maintaining the master training calendar, and conducting monthly reviews of training records. The Administrator is responsible for quarterly audits of training records and overall accountability for ensuring all direct care staff meet training requirements per OAR 411-054-0070. The Facility RN is responsible for documenting observed and evaluated competency demonstrations for medication and treatment administration per OAR 411-054-0070(5)(b)(G).

OAR 411-054-0093 (1-5) Emergency and Disaster Planning An emergency preparedness plan is a written procedure that identifies a facility's response to an emergency or disaster for the purpose of minimizing loss of life, mitigating trauma, and to the extent possible, maintaining services for residents, and preventing or reducing property loss. (1) The facility must prepare and maintain a written emergency preparedness plan in accordance with the OFC. (2) The emergency preparedness plan must: (a) Include analysis and response to potential emergency hazards including but not limited to: (A) Evacuation of a facility; (B) Fire, smoke, bomb threat, or explosion; (C) Prolonged power failure, water, or sewer loss; (D) Structural damage; (E) Hurricane, tornado, tsunami, volcanic eruption, flood, and earthquake; (F) Chemical spill or leak; and (G) Pandemic. (b) Address the medical needs of the residents including: (A) Access to medical records necessary to provide care and treatment; and (B) Access to pharmaceuticals, medical supplies, and equipment during and after an evacuation. (c) Include provisions and supplies sufficient to shelter in place for a minimum of three days without electricity, running water, or replacement staff. (3) The facility must notify the Department, the local AAA office, or designee, of the facility's status in the event of an emergency that requires evacuation and during any emergent situation when requested. (4) The facility must conduct a drill of the emergency preparedness plan at least twice a year in accordance with the OFC and other applicable state and local codes as required. One of the practice drills may consist of a walk-through of the duties or a discussion exercise with a hypothetical event, commonly known as a tabletop exercise. These simulated drills may not take the place of the required fire drills. (5) The facility must annually review or update the emergency preparedness plan as required by the OFC and the emergency preparedness plan must be available on-site for review upon request. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to conduct a drill of the emergency preparedness plan at least twice a year in accordance with the Oregon Fire Code (OFC) and other applicable state and local codes as required. Findings include, but are not limited to: The facility was a licensed RCF with residents housed in three two-story buildings. During the acuity interview on 03/30/26, twelve residents were identified as requiring the assistance of two direct care staff to transfer. Fire and life safety records were reviewed with Staff 1 (Administrator) on 03/31/26 at 1:25 pm. During the interview, Staff 1 reported the facility had not conducted any drills of the emergency preparedness plan, encompassing all three buildings, in the last 12 months. The need to ensure the facility conducted a drill of the emergency preparedness plan at least twice a year in accordance with the OFC and other applicable state and local codes as required was discussed with Staff 1, Staff 2 (Director of Nursing), Staff 3 (Facility RN), Staff 4 (RCC), and Staff 5 (RCC in training) on 04/01/26 at 12:05 pm. They acknowledged the findings.

1. The facility has scheduled a full emergency preparedness evacuation drill encompassing all three buildings (A, B, and C) to be completed within 60 days, no later than May 31, 2026. The drill will include scenarios reflective of the resident population's acuity, including the evacuation of residents who require the assistance of two direct care staff for transfers. In addition, a structured disaster preparedness education session will be conducted for all staff, covering scenarios such as prolonged power outages, addressing how residents' care needs — including medical equipment dependencies — will be managed during an emergency. 2. The facility has established a written emergency preparedness drill schedule that meets at least twice-yearly requirement under the Oregon Fire Code (OFC). The annual drill schedule will include: (1) one full evacuation drill across all three buildings, and (2) one additional drill or tabletop/discussion exercise, which may address a specific disaster scenario such as power failure, water loss, or pandemic response. The emergency preparedness plan has been reviewed and updated to ensure it reflects current resident acuity, including the number of residents requiring two-staff assists for evacuation. Drill completion and outcomes, including any identified gaps, will be documented and retained on-site. Staff and Residents will receive education following each drill to reinforce emergency response procedures. 3. Emergency preparedness drills will be conducted no less than twice per calendar year, in compliance with OAR 411-054-0093 and the Oregon Fire Code. Following each drill or tabletop exercise, the RCC will document the outcome, note any deficiencies identified, and develop a corrective action plan as needed. The emergency preparedness plan itself will be reviewed and updated annually, or sooner if resident acuity, building configuration, or staffing changes warrant a revision. 4. The RCC is responsible for scheduling, coordinating, and documenting all emergency preparedness drills and education sessions. The Administrator is responsible for ensuring drills are conducted within required timeframes, reviewing drill outcomes, and ensuring the emergency preparedness plan remains current. The Facility Nurse will assist in assessing resident-specific evacuation needs and ensuring those needs are reflected in the drill design and emergency plan.

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 residents who lived in the facility were provided a key to their units. Findings include, but are not limited to: During an observation and interview with Resident 1 on 03/30/26 at 1:47 pm, the resident reported having a key to his/her apartment that had not worked since s/he moved in. This surveyor attempted to use Resident 1’s key to unlock the door. The key did not fit the lock. Resident 1 stated that s/he had reported it to the facility and was told the lock “needed to be changed out.” The resident could not recall when s/he reported the issue or to whom the issue was reported to. On 04/01/26 at 11:01 am, Staff 2 (Director of Nursing) confirmed the locking mechanism needed to be changed on Resident 1’s apartment door. On 03/31/26 at 11:30 am, an unsampled resident reported that his/her key did not work in his/her apartment door. The unsampled resident took the surveyor to his/her apartment to demonstrate what the issue was, but the key was not where s/he had thought it would be. The resident stated, “I have no idea where it is.” On 04/01/26 at 11:01 am, Staff 1 (Administrator) confirmed she took the key the previous week as it needed to be replaced but forgot to follow up on the issue. The need to ensure all residents were provided keys to their units was discussed with Staff 1, Staff 2, Staff 3 (Facility RN), Staff 4 (RCC), and Staff 5 (RCC in training) on 04/01/26 at 11:01 am. They acknowledged the findings.

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, the facility failed to ensure move-in evaluations addressed all required elements, including preferred 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.