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 carry out medication and treatment orders as prescribed for 1 of 3 sampled residents (#2) whose orders were reviewed. Findings include, but are not limited to: Resident 2 was admitted to the facility in 04/2021 with diagnoses including atrial fibrillation, age-related osteoporosis and sequelae of cerebral infarction. During the acuity interview on 08/24/26 at approximately 1:00 pm, Staff 6 (CG) reported Resident 2 seemed to have had a recent weight decline. The most current list of signed physician orders, dated 12/17/26, instructed the facility to obtain monthly vitals including blood pressure, respiration, temperature and weight on the 4th of every month. The order included instructions for notifying the licensed nurse and medical doctor (MD) if the above vitals exceeded specific parameters. Review of the 08/2026 MAR indicated the vitals were blank on 08/04/26. No explanation was documented in the resident’s record as to why vitals were not obtained. The need to ensure the facility carried out medication and treatment orders as prescribed was reviewed with Staff 1 (ED), Staff 3 (Regional RN) and Staff 4 (RCC) on 08/26/26 at 3:15 pm. They acknowledged the facility had failed to obtain Resident 2’s vitals as ordered.

Physician and other legally recognized practitioner-ordered medications, treatments, and monitoring parameters, including vital signs and weights, will be carried out as prescribed and documented in the resident record. The Resident Care Coordinator (RCC) or designee will provide competency-based education to all caregiving staff regarding the importance of following physician-ordered treatments and monitoring parameters, including the accurate procedure for obtaining and documenting resident weights. Staff will also be instructed that when an ordered vital sign or weight cannot be obtained, the reason must be documented in the resident record and the appropriate licensed nurse or designee notified according to facility policy. All caregiving staff will complete the competency education by 10/16/2026. The RCC or designee will conduct a monthly audit of a sample of resident records/MARs to verify that ordered vital signs, weights, medications, and treatments are completed as prescribed and appropriately documented. Any identified omission will be immediately addressed with the responsible staff member and the appropriate clinical leadership or designee notified. Additional education or competency validation will be completed as indicated. Compliance will be incorporated into the facility's ongoing monthly clinical record audit process.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by:

OAR 411-054-0300 (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 and surfaces were kept clean and in good repair. Findings include, but are not limited to: a. During an inspection of Resident 2’s unit on 08/25/26 at 11:00 am, it was observed the resident’s carpet was very soiled with dark stains and dried spills and that the unit had a pervasive urine odor. The resident’s couch was also observed to have dried spills and stains. On 08/25/26 at 4:50 pm, Staff 1 (ED) and Staff 2 (Maintenance Director) observed Resident 2’s unit with the surveyor. Staff 1 and Staff 2 acknowledged the odor and condition of the carpet and couch. Staff 1 stated the facility did not have a regular carpet-cleaning schedule but, rather, would clean a resident’s carpet at the resident’s or family’s request. Staff 1 also stated she remembered that Resident 2’s couch was soiled when the resident moved into the facility. Staff 2 stated the facility had slowly replaced resident carpets with laminate flooring but approximately 10 resident units still had carpeting. On 08/25/26 at 5:45 pm, Staff 1 and Staff 2 were observed using a carpet cleaning machine on Resident 2’s carpet. During an interview with Resident 2 on 08/26/26 at 2:50 pm, the resident’s carpet was observed to still be soiled, and the odor was still present in the unit. b. On 08/26/26 at 11:15 am, the surveyor asked Staff 2 to provide a list of resident units that had carpeting; this list was provided at 12:07 pm. It showed 14 resident units had carpeting. On 08/26/26 at 2:10 pm, Staff 1 and Staff 2 conducted observations of the 14 identified rooms with carpeting. The following was noted: * Resident rooms 116, 202 and 210: the carpets were heavily soiled. * Resident room 203: the carpet was moderately soiled and there was a strong cat urine odor present (the resident had a cat). * Resident rooms 106, 114, 204, 212, 216 and 224: the carpets were generally clean except for one or two dried spill or soiled areas. Staff 1 and Staff 2 acknowledged the findings following the room observations. The need to ensure the interior of the facility was free from unpleasant odors, and all interior materials and surfaces were kept clean and in good repair, was reviewed with Staff 1, Staff 3 (Regional RN) and Staff 4 (RCC) on 08/26/26 at 3:15 pm. They acknowledged the findings.

All resident rooms identified as having soiled carpeting will be assessed and cleaned or repaired/replaced as necessary to ensure the carpet is maintained in a clean and sanitary condition and free from unpleasant odors. Maintenance Director or designee will Inservice all staff to report through our TELS system stains, spills, or worn flooring in resident apts and common areas. Resident rooms with identified concerns will be addressed promptly. A quarterly carpet inspection and cleaning process will be established for all resident rooms with carpeting. The Maintenance Director or designee will maintain documentation of carpet inspections and any cleaning, repair, or replacement completed. Environmental Services/Housekeeping staff will be educated on identifying and reporting carpet stains, spills, soiling, and unpleasant odors to the Maintenance Director or designee so concerns can be addressed timely. All existing resident room carpets will be shampooed or replaced, as appropriate based on condition, by 10/19/2026.

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 (5) Resident Units (5) RESIDENT UNITS. All resident units must be accessible per building codes. These apartments must have a lockable entry door with lever type handle, a private bathroom, and kitchenette facilities. Adaptable units are not acceptable.(a) UNIT DIMENSIONS. New construction units must have a minimum of 220 net square feet, not including the bathroom. Units in pre-existing structures being remodeled must have a minimum of 160 square feet, not including the bathroom.(b) RESIDENT STORAGE SPACE.(A) Each unit must provide usable space totaling at least 100 cubic feet for resident clothing and belongings and include one clothes closet with a minimum of four linear feet of hanging space.(B) The rod must be adjustable for reach ranges per building codes. In calculating useable space, closet height may not exceed eight feet and a depth of two feet.(C) Kitchen cabinets must not be included when measuring storage space.(D) A lockable storage space (e.g., drawer, cabinet, or closet) must be provided for the safekeeping of a resident ' s small valuable items and funds. Both the administrator and resident may have keys.(c) WINDOWS.(A) Each resident's living room and bedroom must have an exterior window that has an area at least one-tenth of the floor area of the room.(B) Unit windows must be equipped with curtains or blinds for privacy and control of sunlight.(C) Operable windows must be designed to prevent accidental falls when sill heights are lower than 36 inches and above the first floor.(d) DOORS. Each unit must have an entry door that does not swing into the exit corridor.(A) A locking device must be included that is released with action of the inside lever. Locks for the entry door must be individually keyed, master keyed, and a key supplied to the resident.(B) The unit exit door must open to an indoor, temperature controlled, common-use area or common corridor.(e) BATHROOM. The unit bathroom must be a separate room with a toilet, sink, a roll-in curbless shower, towel bar, toilet paper holder, mirror, and storage for toiletry items.(A) The door to the bathroom must open outward or slide into the wall.(B) Showers must have a slip-resistant floor surface in front of roll-in showers, a hand-held showerhead, cleanable shower curtains, and appropriate grab bar.(f) KITCHENS OR KITCHENETTES. Each unit must have a kitchen area equipped with the following:(A) A sink, refrigerator, and cooking appliance that may be removed or disconnected. A microwave is considered a cooking appliance.(B) Adequate space for food preparation.(C) Storage space for utensils and supplies.(D) Counter heights may not be higher than 34 inches. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. Findings include, but are not limited to: The interior of the building was toured on 08/25/26 at 9:15 am. Multiple second floor resident units were also inspected at various times during the survey. Resident units had either vertical sliding (“single hung”) windows or horizontally sliding windows, or both. The sill heights for all the windows were lower than 36 inches. The following was identified: * Resident rooms 210 and 204 did not have a mechanism to prevent the windows from opening fully to prevent accidental falls from the windows. The need to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor was reviewed with Staff 1 (ED) and Staff 2 (Maintenance Director) on 08/26/26 at 2:10 pm. They acknowledged that not all second-floor resident windows had a mechanism to prevent accidental falls.

Window-opening control devices approved by the State Surveyor will be installed on all applicable operable windows located above the first floor where the window sill height is less than 36 inches. The Maintenance Director or designee will inspect all applicable second-floor resident unit windows and install the approved devices as needed to ensure windows are designed to prevent accidental falls. The Maintenance Director or designee will verify that all applicable windows have the required opening control devices installed and that the devices are properly secured and functioning as intended. All required window-opening control devices will be installed by 10/16/2026. All staff will receive inservice that if they see one missing to report the work order through TELS.

OAR 411-054-0300 (5) Resident Units (5) RESIDENT UNITS. All resident units must be accessible per building codes. These apartments must have a lockable entry door with lever type handle, a private bathroom, and kitchenette facilities. Adaptable units are not acceptable.(a) UNIT DIMENSIONS. New construction units must have a minimum of 220 net square feet, not including the bathroom. Units in pre-existing structures being remodeled must have a minimum of 160 square feet, not including the bathroom.(b) RESIDENT STORAGE SPACE.(A) Each unit must provide usable space totaling at least 100 cubic feet for resident clothing and belongings and include one clothes closet with a minimum of four linear feet of hanging space.(B) The rod must be adjustable for reach ranges per building codes. In calculating useable space, closet height may not exceed eight feet and a depth of two feet.(C) Kitchen cabinets must not be included when measuring storage space.(D) A lockable storage space (e.g., drawer, cabinet, or closet) must be provided for the safekeeping of a resident ' s small valuable items and funds. Both the administrator and resident may have keys.(c) WINDOWS.(A) Each resident's living room and bedroom must have an exterior window that has an area at least one-tenth of the floor area of the room.(B) Unit windows must be equipped with curtains or blinds for privacy and control of sunlight.(C) Operable windows must be designed to prevent accidental falls when sill heights are lower than 36 inches and above the first floor.(d) DOORS. Each unit must have an entry door that does not swing into the exit corridor.(A) A locking device must be included that is released with action of the inside lever. Locks for the entry door must be individually keyed, master keyed, and a key supplied to the resident.(B) The unit exit door must open to an indoor, temperature controlled, common-use area or common corridor.(e) BATHROOM. The unit bathroom must be a separate room with a toilet, sink, a roll-in curbless shower, towel bar, toilet paper holder, mirror, and storage for toiletry items.(A) The door to the bathroom must open outward or slide into the wall.(B) Showers must have a slip-resistant floor surface in front of roll-in showers, a hand-held showerhead, cleanable shower curtains, and appropriate grab bar.(f) KITCHENS OR KITCHENETTES. Each unit must have a kitchen area equipped with the following:(A) A sink, refrigerator, and cooking appliance that may be removed or disconnected. A microwave is considered a cooking appliance.(B) Adequate space for food preparation.(C) Storage space for utensils and supplies.(D) Counter heights may not be higher than 34 inches. This Rule is not met as evidenced by: