Print Inspection: CHOW011039

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 contained all required elements, for 1 of 1 sampled resident (#2) whose move-in evaluation was reviewed. Findings include, but are not limited to: Resident 2 was admitted to the facility in 03/2026 with diagnoses including compression fracture of the third lumbar vertebra, COPD, unspecified osteoarthritis, and atherosclerotic heart disease. The facility used two documents as its move-in evaluations – the electronic “Ashley Manor Evaluation – Oregon (2)” and the handwritten Golden Rose “Pre-Admission Functional Evaluation.” The following elements were not addressed in the evaluations: * Cultural preferences and traditions; * Personality, including how the person copes with change or challenging situations; * Complex medication regimen; * Recent losses; * Unsuccessful prior placements; and * Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting and room temperature. Complex medication regimen and recent losses were not included on the evaluation forms; the other items were not filled in completely on the forms. The information that was lacking regarding the above elements was reviewed with Staff 1 (Interim Administrator), Staff 2 (Universal Worker), and Witness 1 (Consultant/RN) on 04/23/26 at 11:45 am. They acknowledged the information that was lacking.

1. Surveyed resident #2 will have an updated and accurate evaluation completed by 6/1/26. The evaluation elements listed in the SOD have been written in on the service plan currently available to staff. 2. The person assigned to complete evaluations will be trained by an RN consultant or through online training. All evaluations will be reviewed and updated before move-in, 30-days, quarterly, and with significant change of condition. 3. Weekly until all evaluations have been reviewed and updated, then monthly. 4. Administrator or administrator designee.

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 411-054-0040 (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 determine, document, and communicate to staff what actions or interventions were needed for a resident following a change of condition, ensure instructions were resident-specific, and note the progress of the condition at least weekly until resolved, for 2 of 2 sampled residents (#s 1 and 2) who had documented changes of condition. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 12/2024 with diagnoses including vascular dementia, history of Transient Ischemic Attack (TIA), and hypertension. Review of the resident’s record indicated the following: a. There was no documented evidence the facility determined, documented, and communicated to staff what actions or interventions were needed for the resident, and monitored and documented on the progress of the resident’s status at least weekly until the condition was resolved for the following changes of condition: * On 01/25/26 Resident 1 had altered mental status from baseline with concerns for a possible UTI; and * On 04/14/26 staff witnessed the resident slide out of his/her wheelchair onto the floor, and the resident reported his/her left thumb was sore. b. For the following change of condition, there was no documented evidence the facility documented and communicated to staff what actions or interventions were needed for the resident: * On 04/03/26 Resident 1 was found sitting on the fall mat on the floor next to his/her bed. c. For the following changes of condition, the facility failed to document on the status of the condition at least weekly until resolved or failed to document whether the condition was resolved: * On 03/13/26 at 6:20 am Resident 1 was found on the floor mat next to the bed wrapped in his/her blankets with the pressure alarm, which slid off the bed with him/her; and * On 03/13/26 at 4:03 pm Resident 1 was struck in the foot by the wheelchair of another resident when they passed by. d. The resident’s current service plan, dated 03/13/26, included the following fall interventions and supports: * One-person assistance for all transfers; * Use of a bed pressure alarm and wheelchair pressure alarm; * Three to four safety/wellness checks when the resident was in his/her room; and * Remind the resident to use call pendant. The facility documented the following new fall interventions in incident reports in response to falls that occurred between 01/17/26 and 03/13/26: * Motion alarm in the bathroom ensuring the door is kept open while the resident is in bed; * Ensure the resident is up out of bed between 7:00-7:30 am; * Ensure the resident is wearing friction socks/shoes when transferring; and * Fall mat placed at bedside. The facility failed to update the resident’s 03/13/26 service plan with these fall interventions. The facility documented the following additional fall interventions in incident reports in response to falls that occurred after 03/13/26: * Positioning the resident in bed closer to the wall for safety; * Ensure safe positioning while resident is in the wheelchair; * Increase safety checks throughout the day and night; and * Ensure that thirst, toileting, and temperature needs are met. There was no documented evidence the facility documented and communicated these new actions/interventions to staff. During the survey, the use of the pressure alarm, fall mat, motion detector, bed placement, safe footwear, and safety checks were observed to be in place or provided by staff. In an interview on 04/23/26 at 10:00 am, Staff 1 (Interim Administrator) confirmed he had not created temporary service plans (TSPs) documenting what actions or new interventions were needed for the resident for the three falls that occurred between 03/13/26 and 04/14/26. He stated he had communicated the new interventions to the staff verbally. The above changes of condition were reviewed with Witness 1 (Consultant/RN) on 04/23/26 at 10:20 am. She confirmed that for each change of condition Resident 1 should have been placed on alert charting, and a TSP should have been written and shared with staff that instructed staff to monitor the resident’s status until the condition was resolved. The need to ensure the facility determined, documented, and communicated to staff what actions or interventions were needed for a resident following a change of condition and noted progress of the condition at least weekly until resolved, was reviewed with Staff 1, Staff 2 (Universal Worker), and Witness 1 on 04/23/26 at 11:45 am. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 03/2026 with diagnoses including compression fracture of the third lumbar vertebra, COPD, unspecified osteoarthritis, and atherosclerotic heart disease. Review of the resident’s record indicated the following: * On 04/17/26, there was a documented medication error regarding the administration of the resident’s lidocaine pain patch. The facility created a temporary service plan (TSP) that noted “Medication error” and pre-written instructions to “Monitor resident for adverse effects including skin irritation, redness, dizziness or unusual symptoms.” The TSP was reviewed with Witness 1 (Consultant/RN) on 04/23/26 at 10:15 am. She acknowledged the TSP should have noted the issue was related specifically to the lidocaine patch and should have included specific instructions about the location of the body that should be monitored for skin irritation and what other symptoms should be monitored. There was no documented evidence the facility created and documented instructions or interventions that were resident-specific. The need to ensure resident-specific instructions or interventions were determined and documented following a change of condition was reviewed with Staff 1 (Interim Administrator), Staff 2 (Universal Worker), and Witness 1 on 04/23/26 at 11:45 am. They acknowledged the findings.?

1. Surveyed Resident 1 has TSP in place for fall interventions listed in the SOD have been added to the service plan. The UTI has since resolved from 1/25/26. His/her left thumb from 4/14/26 has since resolved. All monitoring and interventions listed in SOD have been resolved and documented. Surveyed Resident 2 TSP for medication change was updated to state which medication was to be monitored. 2. Clinical meetings will be done during weekdays to include a review of all TSPs, alert charting, incident reports, and medication variances. Staff will be educated on how to write TSPs and documents for alert monitoring. 3. Daily, Weekly, Monthly 4. Administrator or administrator designee

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 411-054-0065 (2-6) Administrator: Administrator Requirements (2) FULL ADMINISTRATOR LICENSE. (a) Individuals who applied to the Health Licensing Office by July 1, 2019 and met all requirements of OAR chapter 853, were issued a full residential care administrator license. (b) At any time, individuals who apply to the Health Licensing Office and complete all requirements in OAR chapter 853, including passing the Oregon laws and rules examination, will be issued a full administrator license. (c) By January 1, 2022, all individuals working as an administrator of a residential care or assisted living facility must have obtained this full license. (d) All individuals holding a full administrator license must comply with the annual training requirements and the standards of practice and professional conduct established by the Long Term Care Administrators Board, as outlined in OAR chapter 853, in order to maintain this license, (3) PROVISIONAL ADMINISTRATOR LICENSE. (a) Individuals who applied to the Health Licensing Office by July 1, 2019 but did not meet all requirements in OAR chapter 853, were issued a provisional administrator license. This provisional license expires on December 31st, 2020. Individuals holding a provisional license are required to pass the Oregon laws and rules examination before January 1, 2022 as outlined in OAR chapter 853, in order to continue to work as an administrator. (b) All individuals holding a provisional administrator license must comply with the annual training requirements and the standards of practice and professional conduct established by the Long Term Care Administrators Board, as outlined in OAR chapter 853est. (4) DHS-APPROVED ADMINISTRATOR REQUIREMENTS. (a) Individuals may continue to serve as administrators under the original Department-approved program until January 1, 2022. This Department-approved program requires potential administrators meet the following: (A) Be at least 21 years of age: (B) Possess a high school diploma or equivalent; and (i) Have at least two years professional or management experience that has occurred within the last five years, in a health or social service related field or program, or have a combination of experience and education; or (ii) Possess an accredited Bachelor's Degree in a health or social service related field (b) Facility administrators must meet the following training requirements before employment: (A) Complete a Department approved classroom administrator training program of at least 40 hours; (B) Complete a Department approved administrator training program that includes both a classroom training of less than 40 hours and a Department approved 40-hour internship program with a Department approved administrator; or (C) Complete another Department approved administrator training program. (c) Administrators must have 20 hours of documented Department-approved continuing education credits each year. The approved administrator training program fulfills the 20-hour continuing education requirement for the first year. (d) Persons who have met Department approved training program requirements, but have been absent from an administrator position for five years or less, do not have to re-take the administrator training, but must provide evidence of 20 hours of annual continuing education until January 1, 2022, by which date all administrators must have obtained a residential care administrator license. (e) Before employment as a facility administrator, persons must complete the criminal records check requirements in OAR 407-007-0200 to 407-007-0370 and comply with the tuberculosis screening recommendations in OAR 333-019-0041. An administrator of a facility may not have convictions of any of the crimes described in OAR 407-007-0275. (f) Newly hired administrators are responsible for the completion of form SDS 0566, Administrator Reference Summary, and are required to email or fax the completed form to the Department upon hire. The Department may reject a form that has been falsified or is incomplete. (5) DESIGNEE WHEN ADMINISTRATOR TEMPORARILY ABSENT. The administrator must appoint a staff member as designee to oversee the operation of the facility in the temporary absence of the administrator. Whomever is in charge, whether the administrator or the temporary designee, must at all times: (a) Be in charge on-site. (b) Ensure there are sufficient, qualified staff. (c) Ensure the care, health, and safety needs of the residents are met. (d) If the absence of the administrator is to exceed 30 days, the facility must notify the Department and obtain approval for arrangements prior to the absence. (6) INTERIM ADMINISTRATOR. During times of transition, when the facility does not have a licensed or approved administrator, the facility is responsible for providing administrator functions. In such a situation, the facility must contact the Department immediately and provide the following: (a) Documentation of the background and qualifications of the proposed interim administrator. (b) A completed background check request. Stat. Auth.: ORS 410.070, 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 This Rule is not met as evidenced by: Based on interview, it was determined the facility failed to provide the required documentation to the Department for an interim administrator during times of transition when the facility does not have a licensed or approved administrator. Findings include, but are not limited to: Upon survey entry on 04/20/26, Staff 1 (Interim Administrator) informed the survey team that he was currently in the position of interim administrator. He confirmed he did not hold a “Residential Care Facility Administrator” license. In a follow-up interview on 04/21/26 at 3:00 pm, Staff 1 reported the previous administrator’s last day of work had been 03/09/26 and the facility had not had a licensed administrator who was scheduled to be on-site in the facility at least 40 hours per week since then. He stated the plan was for Staff 2 (Universal Worker) to become the permanent administrator when she completed the administrator training and licensing process. The surveyor contacted the Operations and Policy Analyst for the facility on 04/21/26. She confirmed the facility had failed to submit the documents required for the Department to accept the transition plan. The need to submit the required documentation to the Department for an interim administrator and transition plan was reviewed with Staff 1, Staff 2 and Witness 1 (Consultant/RN) on 04/23/26 at 11:45 am. They acknowledged the findings.

1. The plan for the administrator designee was submitted to the policy analyst and accepted. The administrator designee is in the OHCA administrator course this week (5/11/26-5/15/26). She is onsite a minimum of 40 hours a week. 2. The administrator designee will complete all requirements for a license and become the administrator of record for the community by the AOC date. 3. Weekly until administrator designee becomes licensed and the administrator of record. 4. Administrator or administrator designee, owner.

OAR 411-054-0065 (2-6) Administrator: Administrator Requirements (2) FULL ADMINISTRATOR LICENSE. (a) Individuals who applied to the Health Licensing Office by July 1, 2019 and met all requirements of OAR chapter 853, were issued a full residential care administrator license. (b) At any time, individuals who apply to the Health Licensing Office and complete all requirements in OAR chapter 853, including passing the Oregon laws and rules examination, will be issued a full administrator license. (c) By January 1, 2022, all individuals working as an administrator of a residential care or assisted living facility must have obtained this full license. (d) All individuals holding a full administrator license must comply with the annual training requirements and the standards of practice and professional conduct established by the Long Term Care Administrators Board, as outlined in OAR chapter 853, in order to maintain this license, (3) PROVISIONAL ADMINISTRATOR LICENSE. (a) Individuals who applied to the Health Licensing Office by July 1, 2019 but did not meet all requirements in OAR chapter 853, were issued a provisional administrator license. This provisional license expires on December 31st, 2020. Individuals holding a provisional license are required to pass the Oregon laws and rules examination before January 1, 2022 as outlined in OAR chapter 853, in order to continue to work as an administrator. (b) All individuals holding a provisional administrator license must comply with the annual training requirements and the standards of practice and professional conduct established by the Long Term Care Administrators Board, as outlined in OAR chapter 853est. (4) DHS-APPROVED ADMINISTRATOR REQUIREMENTS. (a) Individuals may continue to serve as administrators under the original Department-approved program until January 1, 2022. This Department-approved program requires potential administrators meet the following: (A) Be at least 21 years of age: (B) Possess a high school diploma or equivalent; and (i) Have at least two years professional or management experience that has occurred within the last five years, in a health or social service related field or program, or have a combination of experience and education; or (ii) Possess an accredited Bachelor's Degree in a health or social service related field (b) Facility administrators must meet the following training requirements before employment: (A) Complete a Department approved classroom administrator training program of at least 40 hours; (B) Complete a Department approved administrator training program that includes both a classroom training of less than 40 hours and a Department approved 40-hour internship program with a Department approved administrator; or (C) Complete another Department approved administrator training program. (c) Administrators must have 20 hours of documented Department-approved continuing education credits each year. The approved administrator training program fulfills the 20-hour continuing education requirement for the first year. (d) Persons who have met Department approved training program requirements, but have been absent from an administrator position for five years or less, do not have to re-take the administrator training, but must provide evidence of 20 hours of annual continuing education until January 1, 2022, by which date all administrators must have obtained a residential care administrator license. (e) Before employment as a facility administrator, persons must complete the criminal records check requirements in OAR 407-007-0200 to 407-007-0370 and comply with the tuberculosis screening recommendations in OAR 333-019-0041. An administrator of a facility may not have convictions of any of the crimes described in OAR 407-007-0275. (f) Newly hired administrators are responsible for the completion of form SDS 0566, Administrator Reference Summary, and are required to email or fax the completed form to the Department upon hire. The Department may reject a form that has been falsified or is incomplete. (5) DESIGNEE WHEN ADMINISTRATOR TEMPORARILY ABSENT. The administrator must appoint a staff member as designee to oversee the operation of the facility in the temporary absence of the administrator. Whomever is in charge, whether the administrator or the temporary designee, must at all times: (a) Be in charge on-site. (b) Ensure there are sufficient, qualified staff. (c) Ensure the care, health, and safety needs of the residents are met. (d) If the absence of the administrator is to exceed 30 days, the facility must notify the Department and obtain approval for arrangements prior to the absence. (6) INTERIM ADMINISTRATOR. During times of transition, when the facility does not have a licensed or approved administrator, the facility is responsible for providing administrator functions. In such a situation, the facility must contact the Department immediately and provide the following: (a) Documentation of the background and qualifications of the proposed interim administrator. (b) A completed background check request. Stat. Auth.: ORS 410.070, 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 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 observation, interview, and record review, it was determined the facility failed to ensure the Acuity-Based Staffing Tool (ABST) and staffing plan incorporated the staffing requirements outlined in OAR 411-054-0070(1)(a) regarding the employment of universal workers. Findings include, but are not limited to: The facility employed universal workers whose duties included other tasks including food service, housekeeping, and laundry. OAR 411-054-0070(1)(a) requires staffing to be increased when the facility employs universal workers, to maintain adequate resident care and services. During the survey, staff were observed preparing, serving, and cleaning up after meals. This process took approximately 45–60 minutes. In an interview on 04/22/26 at 9:55 am, Staff 4 (Universal Worker) acknowledged one staff handled cooking and cleaning for meals and a second staff served the meals. Staff 4 also stated staff did a “deep cleaning” of each resident’s room once per week that she estimated took 20 minutes to complete. She also confirmed staff completed weekly laundry for most of the residents. The ABST and facility staffing plan was reviewed with Staff 1 (Interim Administrator) on 04/22/26 at 12:10 pm. He confirmed that staff were responsible for meal prep, cooking and cleaning afterwards, housekeeping, and laundry. When we reviewed the facility’s ABST, he was not able to explain how the time to complete these extra tasks was incorporated in the ABST or the facility staffing plan. The need to ensure the facility staffing plan incorporated the staffing requirements for universal workers was reviewed with Staff 1, Staff 2 (Universal Worker), and Witness 1 (Consultant/RN) on 04/23/26 at 11:45 am. They acknowledged the findings.

1. All residents will have the ABST reviewed and updated. Staff will be hired according to the updated staffing plan based on the accurate ABST that takes into account the hours for universal workers completing meal prep, cooking, cleaning, and laundry. 2. The ABST will be reviewed and updated with any change of condition and service plan update. 3. Daily, weekly, monthly 4. Administrator or administrator designee

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: