Print Inspection: CHOW010451

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan.(p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the move-in evaluation addressed all required elements for 1 of 1 sampled resident (# 6) and failed to ensure evaluations were performed at least quarterly, to correspond with the quarterly service plan updates, for 3 of 6 sampled residents (#s 1, 3 and 7) whose evaluations were reviewed. Findings include, but are not limited to: 1. Residents 1, 3, and 7’s most recent quarterly evaluations were requested during the survey. During an interview on 03/31/26 at 11:50 am, Staff 6 (Staffing/MT) confirmed there were no quarterly evaluations for Residents 1 and 7. Staff 6 stated the facility was trying to get quarterly evaluations updated. During an interview on 04/01/26 at 12:10 pm, Staff 4 (RCC) confirmed there was no quarterly evaluation to review for Resident 3. The facility had been working on completing residents’ quarterly evaluations but has not “gotten to all of them yet.” The need to ensure resident evaluations were completed at least quarterly was discussed with Staff 1 (ED), Staff 2 (Health Services Director Specialist/LPN) and Staff 4 at 2:43 pm on 04/01/26. They acknowledged the findings. 2. Resident 6 was admitted to the facility on 02/2026 with diagnoses including chronic obstructive pulmonary disease (COPD). A review of the resident’s move-in evaluation identified the following elements were not addressed: * Pronouns; * Cognition, including memory, orientation, confusion and decision-making abilities; * Complex medication regimen; and * History of dehydration or unexplained weight loss or gain. The need to ensure the move-in evaluation included all required elements was discussed with Staff 1 (ED) on 03/31/26 at 1:35 pm. Staff acknowledged the findings.

Resident #6 Evaluation/service plan was updated on 4/13/2026 by the ED to include; pronouns, cognition, basis for complex medication regimin, and any history of dehydration or weight loss/gain. Resident's #1, 3, and 7 evaluation and service plan will be updated to include all required elements including * Pronouns; * Cognition, including memory, orientation, confusion and decision-making abilities; * Complex medication regimen; and * History of dehydration or unexplained weight loss or gain. by the ED/HSD/Designee by 5/1/2026. ED, HSD or Designee will review evaluation tracker in ALIS two times per week for one month, then weekly after that to plan for upcoming evaluation and care plan updates. The Regional Nurse will educated the ED regarding the requirements of the OAR for resident evaluations/service plans. ED/HSD/Designess will audit all resident records to ensure each evaluation/service plan contains the required elements per the OAR. Any identified missing elements will be updated by the ED/HSD/Designee. HSD/Designee will review resident evaluations/CP reports weekly during to ensure care plans are completed & accurate x4 weeks, bi-weekly x 4 weeks then quarterly,ongoing. The results of these audits will be discussed during the monthly Continuous Quality Improvement Committee meeting.

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

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were completed quarterly, readily available to staff, reflective of residents' current care needs, provided clear directions to staff regarding the delivery of services and were implemented for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5 and 7) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 12/2022 with diagnoses including diabetes mellitus and hypotension. Observations of the resident, interviews with staff and resident, review of service plan dated 05/28/25, 12/31/25 through 03/27/26 observation notes and change in plan of communication were completed. The service plan was not reflective, was not implemented and did not provide clear direction for staff in the following areas: * Use of a cushion or a pillow in the wheelchair; * Level of assistance with incontinence care and dressing status; * Conflicting information regarding weight measurements, monthly versus daily; * Sleeping habits and resident preferences; * Using a special boot on the left foot; * Presence of a side rail on the bed; * Use of a sensor to check blood glucose, including care of the sensor; and * Use of hearing aids status. The need to ensure resident service plans were reflective of current care needs, were implemented and provided clear direction to staff was discussed with Staff 1 (ED) on 04/01/26 at 11:59 am. He acknowledged the findings. 2. a. During the acuity interview on 03/30/26, facility staff reported service plans were stored in the service plan binder, located in the MT room for direct care staff to review. Upon observation of the binder at 11:05 am on 03/30/26, the service plans for Residents 1, 3, 4, 5 and 7 were not available to staff at the time of survey entrance. b. There was no documented evidence resident service plans had been updated, at least quarterly, for the following: * Resident 1’s most recent service plan, dated 09/25/25 and Resident 7’s most recent service plan dated 09/05/25, were provided to the survey team on 03/30/26 at 11:33 am; and * Resident 3’s most recent service plan, dated 06/30/25, was provided to the survey team on 03/30/26 at 12:35 pm. During an interview on 03/30/26 at 11:05 am, Staff 6 (Staffing/MT) acknowledged there were multiple service plans in the process of being updated since the change of ownership and were not available to staff. The need to ensure residents’ current service plans were readily available to staff and updated at least quarterly was reviewed with Staff 1 (ED), Staff 2 (Health Services Director Specialist/LPN) and Staff 4 (RCC) at 2:43 pm on 04/01/26. They acknowledged the findings.

ED/HSD/Designees will ensure all residents including residents 1,2,3,4,5, 6 and 7 have a current evaluation and care plans reflective of residents needs within the last quarter by 6/1/26. ED/HSD/Designee will monitor due dates weekly to ensure all evaluations are completed within the time specified. Initial assesments done no more than 30 days prior to admit, move-in assessment done within the first 30 days and quarterly assessments done quarterly. Review EHR and schedule completion of evaluations within required completion days. ED/HSD/ Designee will ensure updated copy of resident evaluation and service plan for all residents will be available in the careplan binder in the med room for all staff to view. The ED/Designee will audit the service plan binder at least monthly x 3 months beginning 6/1/2026 to ensure it is kept up to date. The results of these audits will be reported to the monthly Continuous Quality Improvement Committee. ED, HSD or Designee will review evaluation tracker in ALIS two times per week for one month, then weekly after that to plan for upcoming evaluation and care plan updates. The Regional Nurse will educated the ED regarding the requirements of the OAR for resident evaluations/service plans. ED/HSD/Designess will audit all resident records to ensure each evaluation/service plan contains the required elements per the OAR. Any identified missing elements will be updated by the ED/HSD/Designee. HSD/Designee will review resident evaluations/CP reports weekly during to ensure care plans are completed & accurate x4 weeks, bi-weekly x 4 weeks then quarterly,ongoing. The results of these audits will be discussed during the monthly Continuous Quality Improvement Committee meeting.

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by:

OAR 411-054-0036 (5) Service Plan: Service Planning Team (5) SERVICE PLANNING TEAM. The service plan must be developed by a Service Planning Team that consists of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident. Involved family members and case managers must be notified in advance of the service-planning meeting.(a) As applicable, the Service Planning Team must also include:(A) Local APD or AAA case managers and family invited by the resident, as available.(B) A licensed nurse if the resident shall need, or is receiving nursing services or experiences a significant change of condition as required in 411-054-0045(1)(f)(D) (Resident Health Services).(C) The resident's physician or other health practitioner.(b) Each resident must actively participate in the development of the service plan to the extent of the resident's ability and willingness to do so. If resident participation is not possible, documentation must reflect the facility's attempts to determine the resident's preferences. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a service planning team that consisted of the resident, the resident's legal representative if applicable, any person of the resident’s choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5) whose records were reviewed. Findings include but are not limited to: Resident 1, 2, 3, 4 and 5’s most recent service plans lacked evidence a service planning team reviewed and participated in the development of the service plans. On 03/31/26 at approximately 1:56 pm, the need to ensure service plans were developed by a service planning team was discussed with Staff 1 (ED). No additional information was provided.

ED/HSD/RCC will provide care conferences to all residents and their legal represenentative at the time of the updated evaluation. Documentation of care plan or attempts to schedule a conference will be kept with resident records. All residents will be offered care conference by 6/1/26. Regional Director of Health services will educated the ED on the requirements of a service planning team, The ED/HSD/designee will discuss care conference schedules at standup at least 4 days/week. The ED/HSD will audit updated evaluations/service plans and care conference schedules/documentation weekly x 4 weeks, bi-weekly x 4 weeks or until compliance with service planning team achieved. The results of these audits will be reported to the monthly Continuous Quality Improvement Committee.

OAR 411-054-0036 (5) Service Plan: Service Planning Team (5) SERVICE PLANNING TEAM. The service plan must be developed by a Service Planning Team that consists of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident. Involved family members and case managers must be notified in advance of the service-planning meeting.(a) As applicable, the Service Planning Team must also include:(A) Local APD or AAA case managers and family invited by the resident, as available.(B) A licensed nurse if the resident shall need, or is receiving nursing services or experiences a significant change of condition as required in 411-054-0045(1)(f)(D) (Resident Health Services).(C) The resident's physician or other health practitioner.(b) Each resident must actively participate in the development of the service plan to the extent of the resident's ability and willingness to do so. If resident participation is not possible, documentation must reflect the facility's attempts to determine the resident's preferences. This Rule is not met as evidenced by:

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure short term changes of condition were monitored weekly through resolution and significant changes of condition were evaluated, referred to the facility nurse, documented, and the resident’s service plan updated as needed for 3 of 5 sampled residents (#s 2, 3, and 5) who had documented short term and/or significant changes of condition. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 05/2019 with diagnoses including mild cognitive impairment, type 2 diabetes, and anemia. Resident 5's clinical record, service plan, temporary service plans, incident reports, and observation notes reviewed from 12/30/25 through 03/30/26 revealed the following: On 03/25/26, Resident 5 had three falls out of his/her recliner and was transported to the emergency room for evaluation. On 03/27/26 an RN assessment was completed for a significant change of condition following Resident 5’s falls. Interventions identified from the RN assessment included: * Replace the broken recliner chair in their room; * Place non-skid mat on the seat to prevent slipping; and * “Resident should remain in public areas with line-of-sight supervision during waking hours”. An observation in resident 5’s room on 03/31/26 at 12:05 pm with Staff 1 (ED) revealed the broken recliner chair had not been replaced and the non-skid mat on the seat was covered with a blanket. In interview on 03/31/26 at 1:00 pm, Staff 18 (CG) was not aware of the new interventions or how to implement them. In interview at 2:00 pm on 03/31/26, Staff 4 (RCC) confirmed the service plan had not been updated after the RN assessment was completed. On 4/01/26 at 4:00 pm, the need to update the service plan with the new interventions after a change of condition was reviewed with Staff 1, Staff 2 (Health Services Director Specialist/LPN), and Staff 4. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 12/2022 with diagnoses including diabetes mellitus and hypotension. a. The resident's 03/19/26 service plan, 12/31/25 through 03/27/26 observation notes and 12/18/26 through 03/30/26 outside provider visit notes were reviewed. The resident experienced multiple short-term changes without noted progress at least weekly until resolved in the following areas: * 01/06/26 - A new medication, torsemide for fluid retention; * 02/13/26 – A recurrent pressure sore on the coccyx; and * 03/05/26 – Returned from the emergency room for catheter leakage, pain and received antibiotic treatment for urinary tract infection. During an interview on 03/31/26 at 1:35 pm, Staff 1 (ED), confirmed the changes of condition had not been monitored with weekly progress noted until resolved. No additional information was provided. b. The resident’s 03/19/26 service plan, 12/21/25 through 03/05/26 change in plan of care communication and 12/18/26 through 03/30/26 outside provider visit notes were reviewed and indicated the resident developed a stage 2 pressure sore on the coccyx on 01/12/26, which resolved on 01/17/26, and reoccurred on 02/13/26. There was no documented evidence the facility evaluated the resident, referred the resident to the facility nurse and updated the care plan accordingly. During an interview on 03/31/26 at 12:20 pm, Staff 2 (Health Services Director Specialist/ LPN), reported the facility used a triple-checking system to review documentation of outside provider visit notes. This system included checks by MT, RCC staff and nurses. Although there was a note in the record, she was not aware of the pressure sore and was not able to determine whether other nurses were aware of it. On 03/30/26 at 12:41 pm, the resident was observed using a cushion in his/her wheelchair and on the same day at 12:55 pm, Staff 11 (CG) reported the resident used a pillow in the wheelchair to provide pressure relief. There was no service plan documenting the use of the cushion and pillow while the resident was in the wheelchair. During an interview on 04/01/26 at 10:35 am, Staff 15 (CG) and Staff 18 (CG) reported there was no open wound on the coccyx area and a dry scab was at the previous wound site. The need to ensure short-term changes of condition had documentation of weekly progress until resolution, and significant changes of condition were evaluated, referred to the facility nurse, documented and the resident’s service plan updated as needed was discussed with Staff 1 on 03/31/26 at 1:35 pm. Staff acknowledged the findings. 3. Resident 3 was admitted to the facility in 02/2025 with diagnoses including chronic obstructive pulmonary disease. Review of Resident 3's clinical record, service plan, temporary service plans, after visit summaries, and 12/10/25 through 03/24/26 observation notes revealed the following: * 02/01/26 – A missed dose of tramadol for severe pain; * 02/03/26 – Multiple medication changes included hydrochlorothiazide (for reducing fluid retention) was discontinued, and Vitamin D3 (a supplement) and ondansetron PRN (for nausea) were new; * 02/04/26 – Injury fall; and * 03/04/26 – Routine tramadol for severe pain was discontinued. There was no documented evidence these short-term changes of condition were monitored, with progress noted at least weekly, to resolution. On 04/01/26 at 2:43 pm, Staff 2 (Health Services Director Specialist/LPN) and Staff 4 (RCC) confirmed the identified changes of condition for medications and a fall, and they acknowledged the lack of documented monitoring through resolution. The need to ensure the facility monitored the short-term changes of condition at least weekly through resolution was discussed with Staff 1 (ED), Staff 2, and Staff 4 on 04/01/26 at 2:43 pm. They acknowledged the findings.

HSD/Designee/RN Delegation Nurse will evaluate & document all necessary changes & interventions and TSP's in place for residents #2, 3, and 5. ED/HSD/RN will be reeducated by the Regional Director of Health Services on the need to ensure actions and interventions for short term change in condition were documented and communicated to staff, and monitored weekly until resolution. Guidelines for changes of condition and need to ensure all actions& interventions regarding change in condition, and TSP's are completed. All staff will be educated by the ED/Designee on Temporary Service Plans, reading the binder and signing the acknowledgement of the TSPs. HSD/Designee will track on the nursing audit log change of condition weekly to ensure RN change of condition assessment is completed along with service plan updates. Daily clinical meeting will occure with RCC, Nurse and ED where we will review observation notes and incident reports for any potential significan change of conditions. These changes of conditions will be reported to RN oversight nurse immediately .

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)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have a system in place for tracking controlled substances administered by the facility, for 1 of 1 sampled resident (# 3) whose MARs and controlled substance drug disposition logs were compared for accuracy. Findings include, but are not limited to: Resident 3 moved into the facility in 02/2025 with diagnoses including chronic obstructive pulmonary disease. Resident 3’s 03/01/26 through 03/30/26 MARs and controlled substance disposition log, dated 03/06/26 to 03/30/26, were reviewed and showed the following: * Physician orders for tramadol 50 mg to give 2 tablets twice a day as needed for severe pain; * A dose was signed out in the disposition log on 03/08/26 at 7:30 pm, and the dose was not reflected on the MAR; * A dose was signed out in the disposition log on 03/11/26 at 7:13 pm, and the dose was not reflected on the MAR; * A dose was signed out in the disposition log on 03/13/26 at 6:20 pm, and the dose was not reflected on the MAR; * A dose was signed out in the disposition log on 03/17/26 at 6:23 am, and the dose was not reflected on the MAR; * A dose was signed out on the MAR on 03/07/26 at 10:07 am, and the dose was not reflected on the disposition log; * A dose was signed out on the MAR on 03/08/26 at 5:14 am and the dose was not reflected on the disposition log; * A dose was signed out on the MAR on 03/12/26 at 7:12 pm, and the dose was not reflected on the disposition log; and * A dose was signed out on the MAR on 03/14/26 at 6:28 pm, and the dose was not reflected on the disposition log. The inconsistencies were reviewed on 04/01/26 at 12:51 pm with Staff 2 (Health Services Director Specialist/LPN). She indicated she was not aware of a process to review the controlled substance drug disposition logs for accuracy. Comparison of the remaining quantities of the medication to the disposition log showed the amount left was accurately reflected on the log. The need to ensure the facility had an effective system for tracking controlled substances was reviewed with Staff 1 (ED), Staff 2 and Staff 4 (RCC) on 04/01/26 at 2:43 pm. They acknowledged the findings.

All medication staff will be re-educated by the ED/Regional Director of Health Services on the requirements of tracking/documenting controlled substances. The Regional Director of Health Services/designee will implement the electronic tracking within the EHR system and train all medication staff on the use of this system. The ED/Designee will audit narcotic dispositions/administrations weekly x 4 weeks, then bi-weekly x 4 weeks to ensure compliance. The ED/HSD/Designee will be responsible for reporting the results of these audits to the Continuous Quality Improvement Committee.

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused consent to orders for 2 of 2 sampled residents (#s 2 and 5) who had documented refusals. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 12/2022 with diagnoses including constipation. Resident 2's MARs, dated 03/01/26 through 03/30/26, were reviewed and showed facility staff documented Resident 2 refused the following orders: * Bacitracin (first-aid antibiotic) ointment on three occasions; * Bisacodyl 5 mg (laxative) on 20 occasions; and * Polyethylene powder (laxative) on 46 occasions. There was no documented evidence the prescriber had been notified of the refusals. The need to ensure the facility notified physicians or practitioners of medication refusals was reviewed with Staff 1 (ED) on 03/30/26 at 1:35 pm and Staff 4 (RCC) on 04/01/26 at 1:15 pm. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 05/2019 with diagnoses including mild cognitive impairment, type 2 diabetes, and anemia. Resident 5's MARs, dated 03/01/26 through 03/30/26, were reviewed and revealed facility staff documented Resident 5 refused the following orders: * Acetaminophen 500 mg (for pain) on four occasions; * Bupropion 150 mg (anti-depressant) on two occasions; * Duloxetine 30 mg (anti-depressant) on two occasions; * Famotidine 200 mg (for gastric reflux) on two occasions; * Lithium 300 mg (for bi-polar depression) on two occasions; * Miconazole nitrate 2% (topical anti-fungal) on one occasion; * Nystatin cream (topical anti-fungal) on one occasion; * Senna 8.6 mg (laxative) on two occasions; and * Trospium Chloride (anti-spasmodic) on three occasions. There was no documented evidence the prescriber had been notified of the refusals. On 04/01/26 at 4:10 pm, the need to notify the prescriber when a resident refused to consent to medication orders was reviewed with Staff 1 (Executive Director), Staff 2 (Health Services Director Specialist/LPN), and Staff 4 (RCC). They acknowledged the findings.

On 4/17/26, The ED notified Resident #2 and #5's physician of the medication refusals. ED/HSD/Designee will conduct training with all med techs on company policy for resident refusals. The med tech will complete the physician communication form and fax to physician for every refused medication. Documentation will be maintained in resident physical charts. ED/HSD/Designee to audit daily for two weeks and then once a week for 2 months to ensure completion. The ED/HSD/Designee will report the results of these audits to the Continuous Quality Improvement Committee.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by:

OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents who chose to self-administer medications and had more than one resident in a unit were evaluated for safety and a physician's order was in place for the self-administration for 1 of 1 sampled residents (# 7) who self-administered medications. Findings include, but are not limited to: Resident 7 moved into the facility in 11/2024 with a diagnosis of syncope (fainting). During the acuity interview on 03/30/26, it was identified Resident 7’s medications were administered by Witness 1 (Spouse), who lived in the same apartment with Resident 7. In an interview on 04/01/26 at 2:45 pm, Witness 1 confirmed s/he administered medications to Resident 7. Witness 1 indicated medications were kept in the bathroom, and s/he did not keep medications in a locked container. Review of Witness 1’s physician orders revealed there was no current signed physician's order for Witness 1 to self-administer medications, nor was there a quarterly assessment of Witness 1’s ability to safely self-administer medication, including his/her ability to administer medications to Resident 7. There was no documented evidence the facility had assessed Resident 7's ability to safely have medication in the unit. The need to ensure residents who self-administered their medications and had more than one resident residing in the unit were evaluated quarterly and had a current physician's order for self-administering was reviewed with Staff 1 (ED), Staff 4 (RCC), on 04/02/26 at 9:50 am. They acknowledged the findings.

The ED/HSD/Designee completed a self medication evaluation for resident #7 and Witness #1 on 4/3/26. A written physician order for resident #7 was obtained by the ED on 4/3/26. ED/HSD/Designee will complete self medication assessment and SLUMS for every resident in the community who is designated as a self med and ensure there is a physician order for those resident's to self-medicate. If a physician will not given an order for self-medication, or it is determined through the evaluation that the resident is unable to self administer medications, the community will proceed with administration of those medications. The ED/HSD will be educated by the Regional Director of Health Services on the Self Administration of medication policy. The medication staff will be educated by the ED/HSD/Designee about the self administration of medication policy. The ED/HSD will audit self medication evaluations monthly to ensure they are current per policy.

OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order. This Rule is not met as evidenced by:

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed by an RN, PT, or OT, other less restrictive alternatives evaluated prior to use of the device were documented, caregivers were instructed on the correct use of and precautions for the device, and use of the device was included in the resident's service plan for 1 of 1 sampled resident (#4) who used supportive devices with restraining qualities. Findings include, but are not limited to: Resident 4 was admitted to the facility in 02/2024 with diagnoses including heart failure and chronic kidney disease. Observations of the resident and the resident's room on 03/31/26 at 3:30pm showed a half-length side rail on the side of the bed in the up position that represented a device with restraining qualities. Review of Resident 4's record revealed there was no documented evidence the device with restraining qualities had been assessed by an RN, PT, or OT, no documentation of other less restrictive alternatives evaluated prior to use of the devices, no documentation of instruction to caregivers on correct use of and precautions for the device, and no documentation of the use of the side rails in the resident's service plan. During an interview on 04/01/26 at 4:00 pm, Staff 1 (ED) acknowledged no assessment had been completed for Resident 4's side rail. The need to ensure the use of a supportive device with potentially restraining qualities included documentation of all required elements and the device was included in the resident's service plan was discussed with Staff 1, Staff 2 (Health Services Director Specialist /LPN) and Staff 4 (RCC) on 04/01/26 at 4:05 pm. They acknowledged the findings.

Resident #4 device with restraining qualities supportive device assessment will be completed by the RN. The ED will educate all staff on devices with restraining qualities. The ED/HSD will audit all residents for use of supportive devices with restraining qualities and refer all identified to the RN to complete the assessment and will review all residents to ensure all resident assistive devices are included in evaluations and service plans. The ED/HSD will audit supportive device assessments monthly x 3 months and then quarterly to ensure they are kept up to date.

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 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 ensure the ABST was updated before a resident moved in, whenever there was a significant change of condition, and no less than quarterly at the same time the resident’s service plan was updated to determine appropriate staffing levels to address activities of daily living and other tasks related to care for 4 of 6 sampled residents (#s 3, 5 and 6) and multiple unsampled residents. Findings include, but are not limited to: Review of clinical records, including service plans and/or evaluations for Residents 3, 5 and 6, revealed the facility's ABST was not updated prior to move in, whenever there was a significant change of condition and at least quarterly to reflect the residents' care needs and ensure the ABST accurately determined the needed staffing level. The ABST evaluation date for multiple unsampled residents, reviewed during the survey, revealed the ABST evaluations had not been reviewed and updated in the last 90 days (quarterly). On 03/31/26 at 2:20 pm, the need to ensure the ABST was updated prior to move-in, following significant changes of condition and at least quarterly was discussed with Staff 1 (ED). He acknowledged the findings.

The ED was educated by the Regional Director of Health Services on the requirements of the ABST to be updated prior to move in, at least quarterly and with a change of condition. ED/HSD/Designee have updated all residents in ABSTcurrently. ED to ensure that as each new assesment is completed in ALIS, the update is entered into ABST and a current staffing plan is updated with the date of implementation and posted. ED will also audit monthly to ensure that all residents have been updated in ABST within the last 90 days. The ED/designee is responsible to ensure the ABST is updated appropriately and reflects accurately the time of care for each resident to ensure adequate staffing levels.

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 2 of 4 newly hired sampled staff (#s 12 and 14) completed all required pre-service orientation and dementia training prior to beginning their job responsibilities and providing care for residents. Findings include, but are not limited to: Staff training records were reviewed on 04/01/26 and revealed the following: a. There was no documented evidence Staff 12 (CG) and Staff 14 (CG) both hired 02/25/26, had completed one or more of the following required pre-service orientation topics prior to beginning their job responsibilities: * Abuse reporting requirements; and * Fire safety and emergency procedures. b. There was no documented evidence Staff 14 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 including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach. The need for newly hired staff to complete all required pre-service orientation and dementia training prior to starting their job duties and providing care to residents was discussed with Staff 3 (Business Office Manager) on 04/01/26 and Staff 1 (ED) and Staff 4 (RCC) on 04/02/26 at 9:50 am. They acknowledged the findings.

The ED/BOM will be educated by the Regional Director of Operations and the Regional Director of Health Service on preservice training requirements. ED/BOM will develop plan and schedule for structured orientations to occur in community. ED/BOM have developed master copy of new hire documents to be used in future orientations. ED/BOM will audit all employee files for completeness using audit tools. All files will be audited and completed by 6/1/26. Any staff identified that are missing training will be given a timeline of completion and if they are not completed, they will not be on the schedule. ED/BOM will audit one employee file daily during the daily stand-up meetings. To ensure new files are being completed to standards and in a timely manner.The results of these audits will be reported to the monthly Continuous Quality Improvement Committee. As of 4/28/26 Staff 12&14 have completed all missing and required new hire documented trainings.

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 4 of 4 newly hired sampled staff (#s 8, 12, 13, and 14) demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 04/01/26 and revealed the following: There was no documented evidence Staff 8 (MT), Staff 12 (CG), Staff 13 (CG), or Staff 14 (CG) hired 11/01/25, 01/05/26 and 02/25/26 respectively, demonstrated competency in all assigned job duties within 30 days of hire in one or more of the following areas: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * General food safety, serving and sanitation; and * First aid/abdominal thrust. The need for staff to demonstrate competency in their assigned job duties within 30 days of hire was discussed with Staff 3 (Business Office Manager) on 04/01/25 and Staff 1 (ED) and Staff 4 (RCC) on 04/02/26 at 9:50 am. They acknowledged the findings.

Staff #8, 12, 13, and 14 will have their competencies completed by the RCC/HSD Specialist/Designee. The ED/BOM will be educated by the Regional Director of Operations and the Regional Director of Health Service on training requirements within 30 days of employment. ED/BOM will audit all employee files for completeness using audit tools. All files will be audited and completed by 6/1/26. ED/BOM will audit one employee file daily during the daily stand-up meetings. To ensure new files are being completed to standards and in a timely manner. These audits will be reported to the monthly Continuous Quality Improvement Committee.

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 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure staff were provided with fire and life safety training every other month and to document all required fire drill elements per the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety documentation from 11/2025 through 03/2026 was reviewed on 03/30/26 and 03/31/26. The following was identified: 1. There was no documented evidence all staff were provided with fire and life safety training every other month. 2. Fire drill documentation did not include one or more of the following required elements: * Escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; and * Number of occupants evacuated; and * Evidence alternate routes were used during fire drills. In an interview on 03/30/26 at 3:06 pm, Staff 1 (ED) reported having been employed at the facility for about three weeks and he confirmed no fire and life safety training to staff had been completed with the change of ownership in 11/2025. The need to provide fire and life safety training to all staff on opposite months of fire drills, as well as the need to address all required elements in fire drill documentation, was discussed with Staff 1 on 03/31/26 at 1:35 pm. Staff acknowledged the findings.

The ED will educate the Maintenance Director on the requirements of fire drills and training per the OAR. ED & Maintenance Director will conduct monthly fire drills at the community. The fire drills will be rotated monthly to ensure that each quarter there will be fire drill on each shift. The fire drill will be documented on the Oregon Fire Drill form. The form will be uploaded into TELS and hard copy will be maintained in the Emergency Binder. Oregon fire drill form will be used to ensure the following is documented with every fire drill; * Escape Routes Used * Problems Encountered * Number of Occupants Evacuated * Evidence that Alternative Routes were Used Maintenance Director will conduct monthly fire and life safety training at each all staff meeting. Training topic will be noted on the agenda and kept with the sign in sheet for the meeting. The ED/Designee will audit TELS (maintenance tracking system) monthly. Fire Drills and monthly training will be discused monthly at the CQM meeting.

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

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents were instructed on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building in the event of an actual fire within 24 hours of admission. Findings include, but are not limited to: Fire and life safety documentation from 11/2025 through 03/2026 was reviewed on 03/30/26 and 03/31/26. In an interview on 03/31/26 at 1:34 pm, Staff 1 (ED) was unable to provide documentation that residents were instructed on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the facility within 24 hours of admission for Resident 6. He further stated he reviewed the facility’s admission packet and confirmed it did not include information on general safety procedures. The need to provide fire and life safety instruction to residents within 24 hours of admission was discussed with Staff 1 on 03/31/26 at 1:35 pm. He acknowledged the findings.

The ED will educate the Maintenance Director on the requirements for fire safety training for the residents within 24 hours of move in and annually. Maintenance Director will hold two meetings to train all residents in the community receive proper life safety training. The safety training will include; general safety, evacuation procedures, fire drill responsibilities and designated meeting place in case of a fire. These meetings will take place May 12th and May 28th. Annual training will be scheduled in TELS system for an annual date. The ED/BOM will audit new resident move in files within 24 hours to ensure completion of the fire training.The ED will track the annual training dates and ensure completion.

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:

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the individual and only appropriate staff had a key to access the unit for multiple unsampled residents who resided on the first, second, and third floors. Findings include, but are not limited to: On 04/01/26 at 2:55 pm, an unsampled resident indicated all resident keys could be used on any of the resident unit doors. In an 04/01/26 interview at 3:05 pm, Staff 19 (CG) stated the residents all have the same key, it opened all the apartments, and he was provided the same key. Staff 19 stated if a resident wanted a new key and lock for their apartment door, they would have to tell the administrator. On 04/01/26 at 3:15 pm, the unsampled resident allowed the surveyor to use his/her key to trial other resident’s doors with their permission and the following was revealed: * It was observed the unsampled resident’s key unlocked a total of eight occupied units and two unoccupied units on the three floors. During an interview on 04/02/26 at 9:50 am, Staff 1 (ED) stated he was recently made aware of the key situation, and a plan was in place for new locks and keys for all the resident’s units. The need to ensure the individual and only appropriate staff had a key to access their unit was discussed with Staff 1 and Staff 4 (RCC) on 04/02/26 at 9:50 am. They acknowledged the findings.

The ED and the Maintenance Director will be educated by the Regional Director of Operations on the requirements of residents having access to their own lock and key with appropriate staff having access. Metro Lock Services will be onsite 4/22/26 to rekey all resident rooms and provide the community with keys for all rooms. The ED/MTD will ensure that each resident's key only opens their apartments and that appropriate staff have the key to access the unit. The ED/MTD are responsible to ensure that each apartment is keyed individually.

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by:

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (c) Each resident record must, before move-in and when updated, include the following information: (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name (B) Pronouns. (C) Gender identity. This Rule is not met as evidenced by: Based on interview and record review, the facility failed to ensure move-in evaluations addressed all required elements, including preferred pronouns for 1 of 1 sampled resident (# 6) whose move-in evaluation was reviewed. Findings include, but are not limited to: Refer to: C 252.

Refer to C 252.

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (c) Each resident record must, before move-in and when updated, include the following information: (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name (B) Pronouns. (C) Gender identity. This Rule is not met as evidenced by: