OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medication used to treat a resident's behavior had written, resident-specific parameters, and non-pharmacological interventions were attempted with ineffective results prior to administering the medication for 1 of 1 sampled resident (# 2) who was prescribed PRN medication to address behaviors. Findings include, but are not limited to: Resident 2 moved into the community in 07/2018 with diagnoses including dementia and anxiety disorder. a. The facility failed to ensure there were specific parameters for staff describing how Resident 2 expressed anxiety for the following psychotropic medication: * Lorazepam 0.5 mg twice daily as needed for anxiety. b. The facility administered the PRN Lorazepam six times between 06/01/26 and 07/06/26. There was no documented evidence of non-pharmacological interventions attempted by staff with ineffective results prior to administration. The need to ensure there were resident-specific descriptions of how residents expressed anxiety and non-drug interventions were attempted by staff prior to the administration of PRN psychotropic medication was reviewed with Staff 1 (Administrator), and Staff 13 (Lead MT) on 07/08/26 at approximately 1:00 pm. The staff acknowledged the findings.

Specific parameters for staff describing how Resident 2 expresses anxiety have been added to her MAR. All MAR have been audited to ensure that parameters are in place for all residents utilizing psychotropic medications. All PRN psychotropic medication used to treat resident behaviors wil have written, resident-specific parameters. Non-pharmacological interventions will be attempted with ineffective resuslts being documented prior to administering the medication. In-Service to be perfomed with Med-Techs with RN regarding non-pharmacological intervetions for psychotropic medications on 07/31/26. Lead med tech will audit weekly and notify RN of any needed parameters and interventions that are not in place. RN will complete quarterly audit of all psychotropic medications and all medications without resident specific parameters and interventions will have them added. RN to do a quaterly audit of psychotropic medications to ensure ongoing compliance.

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by:

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents were instructed on fire and life safety procedures within 24 hours of admission for 1 of 1 sampled resident (#1), and to ensure all residents were re-instructed at least annually. Findings include, but are not limited to: Fire and life safety records were requested and reviewed on 07/08/26, and the following was identified: * There was no documented evidence of instruction to residents on general safety procedures, evacuation methods, responsibilities during a fire, and designated meeting places inside or outside the building in the event of an actual fire within 24 hours of admission for Resident 1; and * There was no documented evidence of fire and life safety training provided to residents at least annually. The need to ensure residents received fire and life safety training within 24 hours of admission and at least annually was discussed with Staff 1 (Administrator) on 07/07/26 at 2:40 pm. The Administrator acknowledged the findings.

All Residents will be instructed on fire and life safety procedures within 24 hours of admission and all residents were re-instructed at least annually. Audit to be performed on Fire Life Safety for all residents by Maintanance Director. Documented evidence of instruction to residents on general safety procedures, evacuation methods, responsibilities during a fire, and designated meeting places inside or outside the building in the event of an actual fire within 24 hours of admission for will be conducted by Maintaince Director. AL Administrator will follow up on instruction and documention of instruction for all residents will be stored with AL Administrator for confirmation. Maintanence Director will instruct and document instruction of annual Fire Life Safety Training on general safety procedures, evacuation methods, responsibilities during a fire, and designated meeting places inside or outside the building in the event of an actual fire. Documentation to be stored and reviewed by AL Administrator.

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 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory care communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the grounds were kept orderly and were free of litter and refuse. Findings include, but are not limited to: The exterior of the facility was toured on 07/06/26 at 1:13 pm and the following was identified: * Litter was observed in the front and south sideareas of the building which included gloves, food wrappers, and to-go containers, cigarette butts, and miscellaneous paper products; and * Refuse was observed to be stored behind the fenced-in dumpster area which included household items and durable medical equipment. The facility’s exterior was toured with Staff 1 (Administrator) and Staff 15 (Maintenance Director) on 07/08/26 at 11:37 am. They acknowledged the findings.

The exterior of the facility was cleaned and litter was thrown away. Durable medical equipment was removed. A walk-through of the grounds will be completed daily by the Environmental Services and weekly by AL Administrator and/or Executive Director. The AL Administrator will be responsible for ensuring that these walk-throughs are completed and the exterior of the building is free from litter

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory care communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by:

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the interior of the facility was free from unpleasant odors and all interior materials, surfaces, and equipment necessary for the health, safety, and comfort of the residents were kept clean and in good repair. Findings include, but are not limited to: a. There was a pervasive odor noted during the survey located outside of apartment 226. b. Observations of the facility on 07/06/26 identified the following areas in need of cleaning or repair: * Multiple doors and doorjambs, including residents’ apartment, fire, and office doors, had scrapes, dings, peeling wood, and chipped paint observed; * Wood flooring was scratched, missing pieces, and/or was separating in the hallways, outside of the Medication Room, and inside of apartment 225; * Carpet stains were observed in the library and in some resident apartments; * In the laundry room, there was lint observed behind the dryers, dust accumulation on the air vent and air conditioning unit, and one of the ceiling lights did not turn on; * Multiple walls, including the Veteran recognition wall, had chipped paint, drips, and brown matter present; * Multiple fans, including two located in the dining room, had dust and debris built up, and were observed to be turned on throughout the survey; * There were two buffets located in the dining room observed to have chipped paint or the finish was peeling off and exposing the wood underneath, deeming them to be uncleanable surfaces; * The lower cupboards located in the dining room were observed to have built-up food debris, drips, and gouges exposing the wood which were deemed to be uncleanable surfaces; * The tables and chairs located in the dining room had food debris observed on the legs; * Window sills located throughout the second floor had an accumulation of dust and debris present; and * Built up debris, drips, and scuff marks were observed on the flooring and sides of the elevator. The facility’s interior was toured with Staff 1 (Administrator) and Staff 15 (Maintenance Director) on 07/08/26 at 11:37 am. They acknowledged the findings.

226 cat box was cleaned and added to service plan to ensure cleaning daily. All walls and door frames with chipped paint repainted Floors in hallway and library were repaired and/or replaced by outside vendor Air vents cleaned Fans with debris were cleaned Dining room cupboards were replaced Tables and chairs in dining room were cleaned (tops, bottoms and legs) by staff Window sills were cleaned Elevator flooring (and surrounding areas) were deep cleaned These have been added to current cleaning schedule to be occurring daily. The Environmental Services will be completing weekly walk-throughs for painting, floors, ceilings, AC units, fans to ensure that they are not in need of repair/cleaning. Administrator will be responsible for a twice-weekly walk through to identify areas of cleanliness or repair needed. This will be communicated to the Environmental Services or Cleaning staff and repairs/cleaning will occur within 24 hrs of notification. Administrator will be responsible for ensuring that this is completed.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by:

OAR 411-054-0300 (11-13) Call System (11) CALL SYSTEM. An ALF 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 at each resident bathroom, central bathing rooms, and public-use restrooms.(b) EXIT DOOR ALARMS. Exit door alarms or other acceptable systems must be provided for security purposes and to alert staff when residents exit the ALF. 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.(a) RESIDENT PHONES. Each unit must have at least one telephone jack to allow for individual phone service.(b) PUBLIC TELEPHONE. There must be an accessible local access public telephone in a private area that allows a resident or another individual to conduct a private conversation.(13) TELEVISION ANTENNA OR CABLE SYSTEM. An ALF 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 exit door alarms or another acceptable system for security purposes and to alert staff when residents exited the ALF. Findings include, but are not limited to: The facility was toured on 07/06/26 at 1:13 pm. There were three doorways identified that residents could use to exit the facility. The northside door had an audible alarm installed, but it was turned off. On 07/08/26 at 11:37 am, Staff 15 (Maintenance Director) turned the alarm on and opened the door. He verified being unsure if staff would be able to hear the alarm go off when the door was opened. The southside door was not alarmed. Above the front door, a “motion camera” had been installed. On 07/08/26 at approximately 11:45 am, Staff 1 (Administrator) and Staff 15 verified they did not know if the camera was operable, and if it was, who could see the images and where they could be viewed from. The need to ensure there were exit door alarms or another acceptable system to alert staff when residents exited the ALF was reviewed with Staff 1 and Staff 15 on 07/08/26. They acknowledged the findings.

Facility will ensure all exit door alarms or another acceptable system for security purposes and to alert staff when residents exited the ALF. Alarms linked to call system are installed on all exterior door from AL. North Stair well exit, South Stairwell exit and Main Entry doors have alarms installed by Maintainance Director. Maintainance Director and AL Administrator to do weekly Walk-through to ensure Alarms are active and operating.

OAR 411-054-0300 (11-13) Call System (11) CALL SYSTEM. An ALF 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 at each resident bathroom, central bathing rooms, and public-use restrooms.(b) EXIT DOOR ALARMS. Exit door alarms or other acceptable systems must be provided for security purposes and to alert staff when residents exit the ALF. 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.(a) RESIDENT PHONES. Each unit must have at least one telephone jack to allow for individual phone service.(b) PUBLIC TELEPHONE. There must be an accessible local access public telephone in a private area that allows a resident or another individual to conduct a private conversation.(13) TELEVISION ANTENNA OR CABLE SYSTEM. An ALF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by: