Print Inspection: RL003898

OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the licensee failed to ensure adequate administrative oversight of facility operations and supervision and training of staff. Findings include, but are not limited to: During the re-licensure survey, conducted from 04/21/25 through 04/24/25, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations. Refer to deficiencies in the report.

1) What actions will be taken to correct the rule violation for each example/resident? A) During our weekly quality assurance (QA) meeting, administrator will review the citations in each department. 2) How will the system be corrected so this violation will not happen again? Refer to citation C231 , C260 , C310 , C363, C422 , C610 3) How often will the area needing correction be evaluated? A) Refer to citation C231, C260, C310, C363, C422, C610 4) Who will be responsbile to see that the corrections are completed/monitored? A) Administrator/designee will oversee with additonal oversight from Regional Director of Operations (RDO)

OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals. This Rule is not met as evidenced by:

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure all resident incidents were promptly investigated to rule out abuse and/or neglect and reported to the local SPD office if abuse and/or neglect could not reasonably be ruled out for 1 of 2 sampled residents (#1). Findings include, but are not limited to: Resident 1 was admitted to the facility in 02/2022 with diagnoses including Diabetes. A progress note, dated 01/09/25, indicated Resident 1 had experienced unwanted touching from another resident. The other resident resided in the independent living section of the facility. A incident report dated 01/09/25, noted the independent living resident had “Put [his/her] hands on [Resident 1]’s stomach area and was caressing her without consent”. There was no documented evidence how the facility ruled out suspected abuse or neglect nor was the incident reported to the local SPD office. On 04/22/25 at approximately 2:45pm Staff 1 (Executive Director), stated there was no documented evidence of the facility had reported the incident to the local SPD office. On 04/23/25 at approximately 3:15pm, the need to ensure incidents of abuse or suspected abuse were promptly investigated and reported to the local SPD office was discussed with Staff 1 and Staff 3 (Interim Director of Health Services/LPN). They acknowledged the findings. The facility reported the incident to the local SPD office per the survey team's request. Confirmation of the report was provided to the survey team prior to survey exit.

1) What actions will be taken to correct the rule violation for each example/resident? A) Staff abuse training occurred on May 2, 2025. B) Resident IR has been sent off to the local SPD Office. 2) How will the system be corrected so this violation will not happen again? All IRs to be reviewed daily in clincial meeting with Administrator, Assisted Living Director (ALD), Health Services Assistant (HSA), or RN to ensure reporting happens within 24 hour period. 3) How often will the area needing correction be evaluated? Daily by department heads and weekly by Administrator/Designee, RN during QA meetings 4) Who will be responsible to see that the correction are completed/monitored? Administrator/Designee will review the corrections with additional oversight from Regional RN.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. 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 reflective of residents' current care needs and provided clear instructions to staff for 3 of 3 sampled residents (#s 1, 2, and 3) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 02/2022 with diagnoses including Diabetes. Observations, interviews, and review of the current service plan, dated 03/30/25, revealed the service plan was not reflective of the resident care needs and did not provide clear direction to staff which included a written description of who shall provide the services and what, when, how, and how often the services should be provided in the following areas: * Siderails; *Gait belt; *Cognitive Orientation; and *History of unwanted touching. On 04/24/25, the need to ensure service plans were reflective of resident care needs and included a written description of who should provide the services and what, when, how, and how often the services should be provided was discussed with Staff 1 (Executive Director), Staff 2 (Interim Administrator), and Staff 4 (Regional Director of Health Services/RN). They acknowledged the findings. 2. Resident 2 was admitted to the facility in 10/2024, with diagnoses including diabetes (type II), hypertension, and dysphagia. Review of Resident 2's current service plan, dated 03/31/25, interviews with staff, and observations of the resident revealed the service plan was not reflective of the resident's current status or did not provide clear instructions to staff in the following areas: * Signs and symptoms of hyper/hypoglycemia; * Dietary likes/dislikes, fluid preferences, and diabetic concerns; * Home Health Physical Therapy services, including recommendations; and * Activities. On 04/24/25, the need to ensure service plans were reflective of residents current needs and provided clear directions to staff was discussed with Staff 1 (Executive Director) and Staff 2 (Interim Administrator). They acknowledged the findings. 3. Resident 3 was admitted to the facility in 06/2024, with diagnoses including hypertension, osteoporosis, and macular degeneration. Review of Resident 3's current service plan, dated 04/15/25, and interviews with staff revealed the service plan was not reflective of the resident's current status or did not provide clear instructions to staff in the following areas: *Activities; *Dietary likes/dislikes, and history of dehydration; and *Fall risks and interventions. On 04/24/25, the need to ensure service plans were reflective of residents current needs and provided clear directions to staff was discussed with Staff 1 (Executive Director) and Staff 2 (Interim Administrator). They acknowledged the findings.

1) What actions will be taken to correct the rule violation for each example/resident? A) All service plans have been updated and all required compontents are met. 2) How will the sytem be corrected so this violaton will not happen again? A) Service plans due for the current month will be reviewed in weekly QA meetings and updated if needed. 3) How often will the area needing correction be evaluated? A) Administratior/designee will review weekly during QA meeting. 4) Administrator/designee will oversee the corrections and monitoring. Regional RN will provide additional oversight.

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 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept for all medications that were ordered by a legally recognized provider and administered by the facility, for 3 of 3 sampled residents (#s 1, 2 and 3) whose MARs were reviewed. Findings include, but are not limited to: Resident 2 and 3's MARs, dated 04/01/25 through 04/21/25, were reviewed during the survey. The following were identified: 1. Resident 2’s MAR lacked reasons for use of the following medications: * Cerave moisturizing cr (453 gm); * Clobetasol .05% cream (30 gm); * Eliquis 2.5 mg; * Folic acid 1 mg; * Insulin glargine-YFGN U100 PEN; * Insulin lispro 100 UNIT/ML PEN; * Januvia 50 mg; * Jardiance 10 mg; * Lidocaine-prilocaine 2.5% CRM; * Methotrexate 2.5 mg; * Multivitamin W/MIN; * Pantoprazole sod DR 40 mg; * Simvastatin 20 mg; * Tamsulosin hcl .4 mg; * Tetrabenazine 25 mg; * Vitamin B12 1000 MCG; and * Vitamin D3 25 NCG. 2. Resident 3’s MAR lacked reason for use of the following medications: * Gabapentin 100 mg; * Lisinopril 2.5 mg; and * Multivitamin tab. On 04/24/25, the need to ensure an accurate MAR was kept for all medications that were ordered by a legally recognized provider and administered by the facility was discussed with Staff 1 (executive Director) and Staff 2 (Interim Administrator). They acknowledged the findings. 3. Resident 1 was admitted to the facility in 02/2022 with diagnoses including Diabetes. Review of Resident 1's 04/01/25 through 04/21/25 MAR/TAR, identified the following routine medications lacked a reason for use: * Loratadine 10mg; * Senexon-S 50-8.6mg; * Sertraline 100mg; * Warfarin 2.5mg; and * Warfarin 5mg. On 04/24/25, the need to ensure all medications included reason for use was discussed with Staff 1 (Executive Director), Staff 2 (Interim Administrator), and Staff 4 (Regional Director of Health Services/RN). They acknowledged the findings.

1) What actions will be taken to correct the rule violations for each example/resident? A) MARS were reviewed and reason for giving were added, if needed. MARS were then reviewed by the Regional RN. 2) How will the system be corrected so this violation will not happen again? A) Administrator and Regional LPN reviewed/trained how to add diagnosis to drs orders. B) Director of Health Services (RN) reviews MARS against dr.'s orders. 3) How often will the area needing correction be evaluated? Administrator/designee will review new orders daily in clincal meeting for each new order. 4) Who will be responsible to see that the corrections are completed/monitored? A) Administrator/designee will oversee the corrections and monitoring. Regional RN will provide additional oversight.

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

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to complete or update and review the ABST evaluation for each resident before a resident moved in, whenever there was a significant change of condition, or with a quarterly service plan update, for 3 of 3 sampled residents (#s 1, 2 and 3) whose records were reviewed. Findings include, but are not limited to: On 04/21/25, review of the facility's ABST entries was completed and showed the following: * Resident 1’s ABST was not updated following a significant change of condition; * Resident 2 was not entered into the ABST; * Resident 3’s ABST was not updated with quarterly service plan update. On 04/24/25, the need to ensure the ABST was completed or updated, and reviewed for each resident before move-in, following significant changes of condition, or with quarterly service plan updates was discussed with Staff 1 (Executive Director) and Staff 2 (Interim Administrator). They acknowledged the findings.

1)What action will be taken to correct the rule violation for each example/resident? A) ABST has been updated to reflect current care times. 2) How will the system be corrected so this violation will not happen again? Administrator trained ALD, HSA, Regional RN and Regional LPN on how to update the ABST when they are making changes to the care plans. 3) How often will the area needing correction be evaluated? Adminsitrator/designee, ALD, HSA, RN and will review during the weekly QA meetings and updated if needed. 4) Who will be responsible to see that the correction are completed/ Monitored? Administrator/designee will oversee with additonal oversight from Regional RN.

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 411-054-0090 (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 all requirements were met for fire safety preparedness, instruction and documentation. Findings include, but are not limited to: On 04/22/25 review of facility records and interviews with staff identified the following deficiencies: * There was no documented evidence that residents received instruction on fire safety procedures within 24 hours of admission; and * There was no documented evidence residents were re-instructed, at least annually, in fire safety topics. On 04/24/25, the need to ensure all requirements were met for fire safety preparedness, instruction and documentation was discussed with Staff 1 (Executive Director) and Staff 2 (Interim Administrator). They acknowledged the findings.

1)What action will be taken to correct the rule violation for each example/resident? A) Maintence director with maintenance assistance performed all fire life safety training with AL residents the week of 04/05-09/2025. 2) How will the system be corrected so this violation will be corrected so this violation will not happen again? A) Maintenance director or maintenance assistant will be notified 7 days in advance to provide fire life safety training to the new resident at least 24 hours prior to move in. 3) How often will the area needing correction be evaluated? A) Administrator/designee will review within 24 hours of move in. B) The fire life safety training acknowledgement will be reviewed during weekly QA meetings until in substantial compliance. 4) Who will be responsible to see that the corrections are completed/monitored? A) Administrator/designee will oversee with additonal oversight from RDO

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by:

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory care communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses were maintained in good repair. Findings include, but are not limited to: The exterior of the facility was toured on 04/21/25 and 04/22/25. Exterior pathways around the perimeter of the building contained drop-offs up to three inches, measured from the concrete to the ground. These drop-offs created potential fall hazards for residents. On 04/22/25, the building's exterior was toured Staff 1 (Executive Director) and Staff 2 (Interim Administrator). They acknowledged the findings.

What actions will be taken to correct the rule violation for each example/reside? 1.Maintence director has called Cedar Landscaping Company and areas corrected by service vendor. How will the system be corrected so this violation will not happen again? 2.Administrator reviewed environmental findings with the landscaping company and maintenance to conduct daily walks around the Community. How often will the area needing correction be evaluated? 3.Landscaping company corrected the drop off points. Maintenance will conduct dailys walks for review, and Administrator will conduct weekly walks for review, until substantial compliance is met. 4.Who will be responsible to see that the correction are completed/monitored? Administrator/designee will oversee with additonal oversight from RDO.

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