Print Inspection: CHOW006399

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to determine, document and communicate to staff what actions or interventions were needed for a resident following a short term change of condition and failed to document weekly progress until the condition resolved for 2 of 6 sampled residents (#s 2 and 4) who experienced short term changes of condition requiring monitoring. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 06/2025 with diagnoses including unspecified dementia, cerebral infarction, congestive heart failure, chronic obstructive pulmonary disease (COPD), chronic kidney disease and unsteadiness on feet. Progress notes from admission to 08/24/25, the resident’s initial and current service plan (updated 07/10/25), incident reports, wound evaluations and the “Task List Report” (which contained updates to the resident’s service plan and instructions for staff for responding to changes of condition) were reviewed during the survey. Resident 4 had four falls, three of which resulted in minor injuries. The following was identified: a. On 06/29/25, Resident 4 slid out of his/her wheelchair. The resident sustained a skin tear to the left elbow. Staff were instructed to provide checks at routine intervals, observe for increased confusion, drowsiness, headache, dizziness, personality changes, changes in ability to transfer or ambulate, bruising and pain. There was no documented evidence the facility monitored the resident as instructed. * The facility documented on the progress of the skin tear to the left elbow on 07/10/25, 07/22/25 and 07/31/25. This did not meet the requirement for weekly monitoring. The 07/31/25 note indicated the wound was not resolved. No further monitoring of the wound was documented. b. On 07/10/25, Resident 4 had two falls, the second of which resulted in a skin tear to the left inner arm. Staff were instructed to document and observe each shift as above and to also note the resident’s level of pain (between 1-10) and any pain meds given. There was one monitoring note dated 07/14/25 that read, “Resident voiced no complaints of discomfort through the shift.” The monitoring instructions were documented as discontinued on 07/16/25 but did not indicate if the change of condition was determined to be resolved. * The facility documented on the progress of the skin tear to the left inner arm on 07/14/25. The 07/14/25 note indicated the wound was not resolved. No further monitoring of the wound was documented. c. On 08/02/25 Resident 4 had a fall in his/her room. Staff documented the resident sustained a skin tear to the top of the right hand. There was no documented evidence the facility determined, documented and communicated to staff what actions or interventions were needed and failed to document weekly progress of the resident’s mobility and injury until the conditions resolved. The need to ensure the facility implemented an effective system for responding to resident changes of condition was discussed with Staff 1 (ED), Staff 2 (RN/Health Services Director), Staff 12 (Regional Director of Operations) and Staff 13 (ED in Training) on 08/27/25. They acknowledged the findings. No additional documentation was provided. 2. Resident 2 was admitted to the facility in 08/2022 with diagnoses including atrial fibrillation and congestive heart failure. The resident’s progress notes, dated 05/25/25 through 08/25/25, service plan, dated 07/20/25, and service plan addendums were reviewed. The following was identified: Review of the service plan indicated the resident was able to manage transfers and walking independently as of 07/20/25. On 08/01/25, staff documented the resident was sent to the hospital due to lethargy and weakness. In an interview on 08/26/25, Staff 2 (RN/Health Services Director) indicated the resident was treated at the hospital for excess carbon dioxide levels. The resident returned home on 08/05/25 and was placed on alert monitoring for “return from hospital.” Staff documented the resident needed assistance with walking after the hospital return. There was no documented evidence the facility determined actions or interventions related to the increased need for ADL assistance or communicated any actions or interventions to staff. Staff documented on 08/10/25 the resident still needed assistance with daily tasks. No further monitoring of the resident’s lethargy and weakness was documented, nor was there documentation of resolution of the short-term change of condition. In an interview on 08/26/25, Staff 2 stated the resident had returned to baseline status with ADLs, lethargy, and weakness. The need to ensure the facility determined, documented and communicated to staff what actions or interventions were needed and documented weekly progress to resolution following a short-term change of condition was discussed with Staff 1 (ED), Staff 2, Staff 12 (Regional Director of Operations) and Staff 13 (ED in training) on 08/27/25. They acknowledged the findings.

In referenece to OAR 411-054-0040 (1-2) Change of Codition. 1. Actions to be taken to correct the rule violation for each example: Medication Technician Communication & Documentation Training on Change in Condition * Medication Technicians will receive training on identifying and documenting short-term changes in condition and when to notify the nurse. * Training will include proper documentation procedures and recognition of early signs that may indicate a change in resident status.Training will be acknowlegded and documented and signed by trainee and trainer. 2. System Corrections: Shift-to-Shift Communication * At every shift change, Medication Technicians will participate in a shift-to-shift handoff with all staff. This handoff must include updates on: - Short-term changes in condition - Falls or incidents - Skin integrity concerns - Medication changes - Any unusual observations or behaviors Documentation Requirements * All shift-to-shift communications must be logged on PCC. PCA's will be trained on how to document on the POC and will be signed off acknowledging. 3. Evaluation: *Nurses will review during clinical meetings to ensure accountability and follow-up and ensure appropriate resolution of short-term changes in condition *The Community Nurse will either attend the shift-to-shift handoff or communicate updates via PCC *All Medication Technicians will be informed of short-term and long-term changes in condition through these channels. 4. The Health & Wellness Director and Assistant Health and Wellness Director will be responsible for ensuring these corrections are monitored and completed

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

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure physician's orders were carried out as prescribed for 3 of 6 sampled residents (#s 1, 4 and 6) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 05/2025 with diagnoses including stroke and type 2 diabetes. Review of Resident 6’s MAR, dated 08/01/25 through 08/25/25, and current physician's orders, dated 07/29/25, identified the following: a. Glipizide was ordered to be administered one tablet in the morning for diabetes, give 30 minutes before meal, skip if pre-meal CBG was less than 100. The MAR indicated there were four occasions the pre-meal CBG was less than 100, and the medication was administered. b. Carvedilol was ordered to give one tablet two times a day for hypertension, hold for systolic blood pressure less than 100 or heart rate less than 60. The MAR lacked documented evidence the resident’s blood pressure and/or heart rate were taken prior to the medication being administered 49 times from 08/01/25 to 08/25/25. The need to ensure physician orders were carried out as prescribed was reviewed with Staff 2 (RN/Health Services Director), Staff 1 (ED), Staff 12 (Regional Director of Operations), and Staff 13 (ED in training) on 08/26/25 and 08/27/25. They acknowledged the findings. No further information was provided. 2. Resident 1 was admitted to the facility in 07/2025 with diagnoses which included hypertension and dementia. Review of the MARS, from 07/22/25 through 08/25/25 revealed the resident did not receive the following medications because they were unavailable: * Sertraline HCL 25 mg two tablets daily for dementia was not administered on 15 occasions; * Sodium Chloride tablet twice a day for hyponatremia was not given on 55 occasions; * Cyanocobalamin 1000 mcg once daily for supplement was not given on 32 occasions; * Ergocalciferol capsule once every Friday for supplement was not given on three occasions; * Fiber oral packet once in the morning for constipation was not given on 16 occasions; and * Mirtazapine 15mg one at bedtime for sleep aid was not given on one occasion. In an interview on 08/26/25 at 2:45 pm, Staff 2 (RN/Health Services Director) and Staff 3 (HSD Assistant) verified the medications had not been given as prescribed. Staff 2 stated that all medications, except for cyanocobalamin (facility working with family to provide the medication) were available as of the survey and being given as ordered. The need to ensure medications were available and administered as prescribed was reviewed with Staff 1 (ED), Staff 12 (Regional Director of Operations) and Staff 13 (ED in training) on 08/27/25. They acknowledged the findings. 3. Resident 4 was admitted to the facility in 06/2025 with diagnoses including unspecified dementia, cerebral infarction, congestive heart failure, chronic obstructive pulmonary disease (COPD), chronic kidney disease and unsteadiness on feet. Resident 4’s current signed orders and the 08/01/25 through 08/24/25 MAR were reviewed during the survey. The following deficiencies were identified: a. The resident was prescribed fluticasone-salmeterol aerosol powder (an inhaler to treat COPD and asthma), inhale 1 puff into the lungs BID. The MAR indicated the resident was not administered the inhaler as ordered on 08/10/25 (both am and pm doses), 08/16/25 (am dose), 08/17/25 (both am and pm doses), 08/19/25 (pm dose) and 08/20/25 (pm dose). The MT documented “med not available.” b. The resident was prescribed dabigatran etexilate mesylate (an anticoagulant to prevent blood clots) 150 mg capsule, take 1 capsule BID. The MAR indicated the resident was not administered the medication as ordered on 08/01/25 (am dose), 08/03/25 (am dose) and 08/04/25 (am dose). MTs documented “no medication,” “medication not in cart,’ and “medication on order.” The need to ensure medication and treatment orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 2 (RN/Health Services Director), Staff 12 (Regional Director of Operations) and Staff 13 (ED in Training) on 08/27/25. They acknowledged the findings. No additional documentation was provided.

In referenece to OAR 411-054-0055 Systems: Treatment Oreder 1. Actions to be taken to correct the rule violation for each example: Training Requirements *All Medication Technicians must attend a training class conducted by either Community Nurses or an approved external provider.The training course will cover essential topics including: - Hypotension and Hypertension - Vital Signs Monitoring - Diabetes Management - Proper Use of PRN Medications * A sign of acknowledgement and training material will be kept by the nurse 2. System Corrections: * A full Medication Administration Record (MAR) audit will be conducted regularly to ensure accuracy and compliance. 3. Evaluation: Nurses will perform a Physician Order Audit to verify current orders, make necessary adjustments, and implement changes as needed during clinincal meeting 4. The Health & Wellness Director and Assistant Health and Wellness Director will be responsible for ensuring these corrections are monitored and completed

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

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was maintained for all facility administered medications for 1 of 6 sampled residents (#1) whose MARs were reviewed. Findings include, but are not limited to: Resident 1 was admitted to the facility in 07/2025 with diagnoses which included hypertension and dementia. Resident 1 had orders for: * Cyanocobalamin 1000mcg one daily for supplement; * Fiber oral packet once in the morning for constipation; * Sertraline HCL 25 mg two tablets daily for dementia; and * Sodium Chloride tablet twice a day for hyponatremia. According to the MARs, staff documented on multiple occasions between 07/22/25 through 08/25/25 that the medications were not available. However, there were also multiple occasions that staff initialed that the medications were administered during the same time frame. The discrepancies on the MAR were reviewed with Staff 2 (RN/Health Services Director) and Staff 3 (HSD Assistant) on 08/26/25 at 2:45 pm. Both confirmed staff documented that the medications had been administered when they were unavailable. They acknowledged the MAR was inaccurate. The need to ensure MARs were accurate was discussed with Staff 1 (ED), Staff 12 (Regional Director of Operations) and Staff 13 (ED in training) on 08/27/25. They acknowledged the findings.

In reference OAR 411-054-0055 (2) System: Medication Administration. 1. Action to be taken to correct rule violation for each example: * All Medication Technicians must complete the Medication and Treatment Course offered by Oregon Care Partners or work day.. * New competency forms will be completed upon course completion. * Attendance in mandatory classes led by the Community Nurse on proper medication administration is required and will be completed by 9/30/2025. Signed acknowledgement of attendace 2. System Corrections: * Medication Technicians must promptly notify the Community Nurse if any prescribed medication is unavailable. * A full audit of the medication cart will be conducted weekly. *All audit findings must be logged and reviewed for accuracy. * Noc shift Med Techs will conduct weekly Cart audits. * The RCC (Resident Care Coordinator) will ensure a proper count of all medications at the start of each month to maintain inventory integrity.Community Nurse will run medication not available report and will go over at chinicals daily. 3. Evaluation: * Evaluation will occur weekly through cart audits and clinical meeting and monthly for inventory integrity. 4. The Health & Wellness Director and Assistant Health and Wellness Director will be responsible for ensuring these corrections are monitored and completed

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by:

OAR 411-054-0037 (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 update and review the acuity-based staffing tool (ABST) evaluation for each resident no less than quarterly at the same time the resident’s service plan was updated. Findings include, but are not limited to: The facility used the Department’s Acuity-Based Staffing Tool. The data contained in the ABST was reviewed on 08/26/25. At the time of the survey, there were 70 residents residing in the assisted living facility. The following was identified: * Twenty-one current residents’ individual ABST evaluations had not been updated within the last 90 days (quarterly). The need to ensure the facility had a process for updating and reviewing each resident’s ABST evaluation no less than quarterly at the same time the resident’s service plan was updated was discussed with Staff 1 (ED), Staff 2 (RN/Health Services Director), Staff 12 (Regional Director of Operations) and Staff 13 (ED in Training) on 08/27/25. They acknowledged the findings.

In refernece OAR 411-054-0037 (4-6) Acuity Based Staffing Tools Updates & Staffing Plan. 1. Actions taken to correct the rule violation: * Review and update the ABST (Acuity Based Staffing Tool) to ensure that each current residents’ information is updated within 90 days of the previous review. 2. System Corrections: * Review and update the ABST (Acuity-Based Staffing Tool): - Prior to move-in - Whenever there is a significant change in condition - At least quarterly, in conjunction with the Service Plan update * A checklist system has been implemented to confirm all steps of the current care plan are completed during a quarterly review which includes review of the ABST to ensure it’s timely completion 3. Evaluation * Evaluation will be completed weekly during clinical meetings 4. The Health & Wellness Director and Executive Director will be responsible for ensuring these corrections are monitored and completed

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:

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure pre-service orientation in all required topics was completed prior to beginning job duties for 3 of 4 newly hired staff (#s 6, 8 and 9) whose training records were reviewed. Findings include, but are not limited to: Staff training records were reviewed on 08/26/25 and the following was identified: a. There was no documented evidence Staff 6 (MT), hired on 07/08/25, Staff 8 (Housekeeping) hired on 06/06/25, and Staff 9 (CG) hired on 04/10/25, had completed one or more of the following required pre-service orientation topics prior to beginning their job responsibilities: * Resident rights and values of CBC care; * Fire safety and emergency procedures; * Infectious Disease Prevention; * An approved HCBS course; and * An approved LGBTQIAS+ course. b. There was no documented evidence Staff 6 (MT) had completed one or more of the following pre-service dementia care training topics: * Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to behaviors; reducing use of antipsychotics; * Strategies for addressing social needs and engaging them in meaningful activities; and * Specific aspects of dementia care including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach. The need to ensure staff completed all required pre-service orientation trainings and for direct care staff to complete required pre-service dementia training was discussed with Staff 1 (ED) on 08/26/25 at 10:55 am. He acknowledged the findings.

In reference to OAR 411-054-0070 Pre-Service Training Requirements 1. Actions to be taken to correct the rule violation for each example: *All newly hired employees must complete pre-service training prior to beginning any duties on the floor. *Training must cover all required competencies and be documented in accordance with state regulations. * A comprehensive audit of training records will be conducted for all staff 2. System Corrections * A training tracker sheet will be maintained, listing individual classes each employee must complete, along with specific deadlines for completion. * The Office Manager will require proof of completion of pre-service trainings prior to scheduling employee for job duties. 3. Evaluation: * The Office Manager and concierge will assist in monitoring and updating the tracker to ensure accuracy and accountability. 4. The Executive Director will ensure the corrections are completed by review of new employee files and review of the training tracker

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by:

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 3 direct care staff (#s 6, 7 and 9) whose records were reviewed demonstrated satisfactory performance in all required areas within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 08/26/25. The following was identified: There was no documented evidence Staff 6 (MT) hired 07/08/25, Staff 7 (MT) hired 05/06/25, and Staff 9 (CG) hired 04/10/25, had demonstrated competency in some or all of the following required areas and within 30 days of hire including: * Role of service plans in providing individualized care; * Providing assistance with ADL's; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; and * Conditions that require assessment, treatment and observation and reporting. Additionally, there was no documented evidence Staff 6 had completed First Aid certification and abdominal thrust training. The need to ensure staff had demonstrated competence in all job duties within 30 days of hire and completed First Aid certification and abdominal thrust training was reviewed with Staff 1 (ED) on 08/26/25 at 10:55 am. The findings were acknowledged.

In reference to OAR 411-054-0070 (5&9-10) Training within 30 days of hire - Direct Care Staff. 1. Actions to be taken to correct the rule violations for each example: * All staff will be provided with an individualized list of required training courses necessary to remain in compliance with Oregon state regulations. * Each course will be assigned a specific deadline for completion, based on regulatory timelines. * Employees are expected to complete all assigned trainings by the stated deadlines to ensure continued eligibility to provide care and services. * Staff who do not complete training will be pulled from the floor until completed in full. All direct care staff will complete a comprehensive training that includes both knowledge-based instruction and performance demonstrations 2.System Corrections: * Direct care staff will complete required trainings on the role of service plans, providing assistance with ADLs, changes associated with aging, identification of changes and documenting and reporting on the resident’s changes of condition, conditions that require assessment treatment observation and reporting, food safety, abdominal thrust, and first aid prior to beginning job duties to ensure timely completion. 3. Evaluation: The Office Manager and concierge will assist in monitoring and updating the tracker to ensure accuracy and accountability. 4. The Executive Director will ensure the corrections are completed by 10/26/2025

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by:

OAR 411-054-0090 (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 received fire and life safety training within 24 hours of admission for 3 of 3 sampled residents (#s 1, 4 and 6), and annually for 2 of 2 sampled residents (#s 2 and 5) whose fire and life safety training records were reviewed. Findings include, but are not limited to: Fire and life safety records were requested during the survey. The following was identified: * There was no documentation of fire and life safety training provided to Residents 1, 4 and 6 within 24 hours of move in; and * There was no documentation of annual fire and life safety training provided to Residents 2 and 5. The need to ensure residents received fire and life safety training within 24 hours of admission and were re-instructed, at least annually, was discussed with Staff 1 (ED) on 08/26/25 at 1:50 pm. He acknowledged the findings.

In reference to OAR 411-054-0090 (5) Fire and Life Safety:Training for residents. 1. Actions to be taken to correct the rule violation for each example: * The Maintenance Director will meet with new residents within 24 hours of admission to provide fire and Life safety training. * Residents will be re-instructed at least annually to reinforce safety protocols. * If the Maintenance Director is unavailable, the Executive Director will ensure the Fire and Life Safety is completed within the allotted timeframe. * All residents will be notified of the annual fire safety training. * A notice will be posted to announce the upcoming Annual Fire Safety Training scheduled to be completed prior to 10/26/2025 2. System Corrections: * New resident move-ins to the community will be reviewed daily in standup meeting and identified for fire and life safety training to be completed within 24 hours. * Annual Fire and Life Safety community meeting will be held annually. Residents who do not attend will be identified and training will be provided to those residents 1:1. 3. Evaluation: New residents will be identified daily in standup meeting and reviewed additionally in weekly meeting between ED and Maintenance Director 4. The Executive Director will ensure the corrections are completed and monitored

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 maintain all exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways in good repair and free from drop-offs to mitigate potential tripping hazards. Findings include, but are not limited to: On 08/05/25 through 08/06/25 the exterior walking paths and courtyard were toured and the following was identified: * There were multiple uneven concrete seams noted throughout the courtyard and along the walking path surrounding and in front of the building. The need to ensure pathways and exterior surfaces were maintained in good repair and did not have potential hazards was discussed with Staff 11 (Maintenance Director) during a tour of the exterior grounds on 08/25/25 at 12:00 pm, and reviewed with Staff 1 (ED), Staff 12 (Regional Director of Operations) and Staff 13 (ED in training) on 08/27/25. The findings were acknowledged.

In refernece to OAR 411-054-0300 (a-h) General Building Exterior. 1. Actions to be taken to correct the rule violation for each example: *To ensure safe and accessible walkways throughout the community: - The Maintenance Director is responsible for leveling and clearing all community ground pathways of any obstructions or trip hazards. - This includes identifying and addressing uneven concrete slabs, debris, or other physical hazards that may pose a risk to residents, staff, or visitors. - Repairs may be completed by the Maintenance Director or, if necessary, by an outside licensed contractor to ensure proper leveling and compliance with safety standards. 2. System Corrections Routine inspections by the maintenance director and Executive Director and prompt corrective actions will help with a safe environment and reduce the risk of falls or injuries 3. Evaluation: Maintenance Director and Executive Director to discuss general exterior condition and corrective in weekly 1:1 meeting 4.The Executive Director will ensure the corrections are completed and monitored

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 all interior and exterior materials and surfaces and all equipment necessary for the health, safety, and comfort of the resident were kept clean and in good repair. Findings include, but are not limited to: Observations of the facility on 08/25/25 revealed the following: a. Facility entry: * An upholstered chair to the right of the piano had an approximate three-inch tear in the arm rest and discolored stains on the top of the chair back; * An upholstered chair to the left of the piano had stains on the arm rest and seat cushion; * Several stains were observed on the carpet; * Seating benches had scratched/gouged areas on the wooden legs; and * Two chairs near the fireplace had discolored areas on the upholstery. b. Dining room: * Several stains were noted on the carpet throughout; * Holes, worn, and frayed areas were observed along the carpet border; * Metal transition strips leading to the courtyard had an accumulation of dirt and debris; * Pillars had scraped and gouged areas; * A windowsill (near patio doors) had peeling paint and drywall crumbling on the left side; * Windowsills had an accumulation of dead bugs and dust; and * The cabinet underneath the handwash sink had stains and spills on the interior. c. First floor: * Room 105 had a scraped door and/or frame; and * Several carpet stains were observed in the halls. d. Second floor: * Room 201 had a scraped door and/or frame; and * Several carpet stains were observed in the halls. e. Second floor common sitting area: * Two brown chairs had worn, cracked areas on seats and arm rests; * A seating bench near the elevator had scraped areas on the wooden legs; and * Scraped paint on elevator door frame. f. Second floor television area: * Two chairs near the bookshelf had scraped legs; and * Stains on carpet in front of the vending machine. g. First floor common bathroom (on left side) had discolored caulking around the toilet base. h. Exterior smoking area had numerous cigarette butts and trash on the ground. The surveyor toured the interior and exterior environment with Staff 11 (Maintenance Director) on 08/25/25. He acknowledged the findings. The need to ensure interior and exterior materials and surfaces and all equipment necessary for the health, safety, and comfort of the resident was kept clean and in good repair was discussed with Staff 1 (ED), Staff 12 (Regional Director of Operations) and Staff 13 (ED in training) on 08/27/25. The findings were acknowledged.

in reference to OAR 411-054-0300 (4) (D-I) Gerneral Building : Doors, walls, cleanable 1. Actions to be taken to correct the rule violation for each example: * All upholstered furniture will be inspected for cleaning and/or repaired. * Items that cannot be adequately cleaned or repaired will be replaced. * A handheld cleaning machine has been purchased to maintain upholstery cleanliness. This includes upholstered furniture and seating benches. * Wooden components of furniture will be repaired and stained as needed. * A new industrial carpet cleaning machine has been purchased * Damaged areas (holes, worn or frayed sections) will be repaired until carpet replacement occurs. 2. System Corrections: * Carpets will be placed on a routine cleaning schedule. * Spot cleaning will be performed as needed. * Housekeeping staff will receive in-service training on state survey findings and cleaning expectations. * Staff will sign off to acknowledge understanding of cleaning requirements, including: - Metal transition strips - Windowsills - Areas under cabinet hand sinks - Other detailed cleaning zones - Weekly walkthroughs will be conducted in random areas to ensure cleaning meets high standards. 3. Evaluation: * A full-building walkthrough will be conducted routinely by the Executive Director and Maintenance Director to : - evaluate system corrections - create a punch list - Prioritize repairs and painting needs - Include common areas, resident room doors/frames, and common area bathrooms. 4.The Executive Director will ensure the corrections are completed and monitored

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: