Print Inspection: RL004088

OAR 411-054-0025 (7) Facility Administration: Policy & Procedure (7) POLICIES AND PROCEDURES. The facility must develop and implement written policies and procedures that promote high quality services, health and safety for residents, and incorporate the community based care principles of individuality, independence, dignity, privacy, choice, and a homelike environment. The facility must develop and implement: (a) A policy on the possession of firearms and ammunition within the facility. The policy must be disclosed in writing and by one other means of communication commonly used by the resident or potential resident in his or her daily living. (b) A written policy that prohibits sexual relations between any facility employee and a resident who did not have a pre-existing relationship. (c) Effective methods of responding to and resolving resident complaints. (d) All additional requirements for written policies and procedures as established in OAR 411-054-0012 (Requirements for New Construction or Initial Licensure), OAR 411-054-0040 (Change of Condition and Monitoring), OAR 411-054-0045 (Resident Health Services), and OAR 411-054-0085 (Refunds and Financial Management). (e) A policy on smoking. (A) The smoking policy must be in accordance with: (i) The Oregon Indoor Clean Air Act, ORS 433.835 to 433.875; (ii) The rules in OAR chapter 333, division 015; and (iii) Any other applicable state and local laws. (B) The facility may designate itself as non-smoking. (f) A policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner. The policy must include information regarding the collection of medical and forensic evidence that must be obtained within 86 hours of the incident. (g) A policy on facility employees not receiving gifts or money from residents. (h) Protocols for preventing and controlling infection, as described in OAR 411-054-0050. (i) LGBTQIA2S+ Nondiscrimination Notice: “(Name of care facility) does not discriminate and does not permit discrimination, including but not limited to bullying, abuse or harassment, based on an individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status, or based on an individual’s association with another individual on account of the other individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status. If you believe you have experienced this kind of discrimination, you may file a complaint with the Oregon Department of Human Services at (provide current contact information).” (j) ABST Policy for accurate and consistent implementation of the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to: During the survey, interviews were conducted with sampled and unsampled residents who expressed their concerns regarding complaints being unaddressed. Examples given included: * Multiple complaints regarding food, including taste, temperature, and texture; * Activities; * Extended wait times of up to one hour and 15 minutes after pressing call pendant; * ADL care being completed, including showers; and * Medication management. On 04/30/25 at 8:15 am, Staff 1 (Regional Director of Operations) was interviewed about the facility's grievance resolution policy. She stated the facility had previously had a suggestion box and a grievance resolution form, which included documenting the response to and resolution of resident complaints. However, the suggestion box and the form were no longer located at the front desk for residents to access. In an interview with Resident 7 on 04/29/25 at 10:40 am, s/he indicated the Resident Council meeting minutes are reviewed line by line with the administrator following the meetings but there has been no consistent resolution. “And what was told to me by former administrators has not always been honored by the current administrators coming in. It is very frustrating.” The need to ensure the facility had an effective method of responding to and resolving resident complaints was discussed with Staff 1 and Staff 2 (Regional Nurse Consultant) on 05/01/25 at 9:50 am. The findings were acknowledged.

1. The facilty will implement a compreshensive grievance program that is accessible to all residents. 2. Each department head will review any complaints submitted throught the grievance process and address them directly with the resident invloved. 3. Once a grievance is resloved, it will be reviewed and signed off by the facility Executive Director to ensure proper closure. 4. All staff will complete training on resident rights and the facility grievance procedures to ensure awareness and consisitent handlingof concerns. 5. Resdient Council meetings will contuined to be held on the first Thursday of each month. 6. After each meeting, the Social Service Director and Executive Director will meet will meet with the resident council president to discuss and review any concerns raised. 7. The Dietary Director will distribute and collect monthly surverys from residents and gather feedback on food-relared concerns, including taste, temperature, and texture. 8. All dietary sureverys will be reviewed by the Executive Director, and the on going food committee meeting will contuine under the oversight of both the Executive Director and Dietary Director. 9. The Resident Care Coordinator and Social Service Director will gneerate and review daily call light sysytems throughout the day to ensure that call light times are no more than 15 minutes. 10. After all light times are reviewed SSD and RCC will follow-up with the resident. 11.The Executive Director will review call light times with the leadership team.

OAR 411-054-0025 (7) Facility Administration: Policy & Procedure (7) POLICIES AND PROCEDURES. The facility must develop and implement written policies and procedures that promote high quality services, health and safety for residents, and incorporate the community based care principles of individuality, independence, dignity, privacy, choice, and a homelike environment. The facility must develop and implement: (a) A policy on the possession of firearms and ammunition within the facility. The policy must be disclosed in writing and by one other means of communication commonly used by the resident or potential resident in his or her daily living. (b) A written policy that prohibits sexual relations between any facility employee and a resident who did not have a pre-existing relationship. (c) Effective methods of responding to and resolving resident complaints. (d) All additional requirements for written policies and procedures as established in OAR 411-054-0012 (Requirements for New Construction or Initial Licensure), OAR 411-054-0040 (Change of Condition and Monitoring), OAR 411-054-0045 (Resident Health Services), and OAR 411-054-0085 (Refunds and Financial Management). (e) A policy on smoking. (A) The smoking policy must be in accordance with: (i) The Oregon Indoor Clean Air Act, ORS 433.835 to 433.875; (ii) The rules in OAR chapter 333, division 015; and (iii) Any other applicable state and local laws. (B) The facility may designate itself as non-smoking. (f) A policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner. The policy must include information regarding the collection of medical and forensic evidence that must be obtained within 86 hours of the incident. (g) A policy on facility employees not receiving gifts or money from residents. (h) Protocols for preventing and controlling infection, as described in OAR 411-054-0050. (i) LGBTQIA2S+ Nondiscrimination Notice: “(Name of care facility) does not discriminate and does not permit discrimination, including but not limited to bullying, abuse or harassment, based on an individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status, or based on an individual’s association with another individual on account of the other individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status. If you believe you have experienced this kind of discrimination, you may file a complaint with the Oregon Department of Human Services at (provide current contact information).” (j) ABST Policy for accurate and consistent implementation of the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. This Rule is not met as evidenced by:

OAR 411-054-0025 (9) Facility Administration: Quality Improvement (9) QUALITY IMPROVEMENT PROGRAM. The facility must develop and conduct an ongoing quality improvement program that evaluates services, resident outcomes, and resident satisfaction. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure they conducted an ongoing quality improvement program that evaluated services, resident outcomes, and resident satisfaction. Findings include, but are not limited to: During the survey, conducted 04/28/25 through 05/01/25, quality improvement oversight to ensure adequate resident care, services, and satisfaction was found to be ineffective. Refer to the citations in the report. The need to ensure the facility conducted an ongoing quality improvement program that evaluated services, resident outcomes, and resident satisfaction was discussed with Staff 1 (Regional Director of Operations) and Staff 2 (Regional Nurse Consultant on 05/01/25. No additional information was provided.

1. The facility will establish and contuct a Quality Assurance Performance Improvement Committee meeting on a quarterly basis to address and review areas of concerns through out the facility. 2. The QAPI committee will composed of each department and Executive Director, who will collaborate to analyze data, identify trends, and develop action plans as needed. 3. The Committee's focus areas will include, but not limited to: Falls Medication Errors Nurse Delegations Medication room audits Safety committee Reviews Residend Satisfaction Surveys Employee Satisfaction Surveys Resident Council Concerns Grievances Dietary surevey resulst. Activites updates 4. Each department will be responisble for reports data and upadtes related to their specific area during QAPI meeting. 5. Action items and follow-ups from each QAPI meeting will be documented, assigned to responsible individuals and monitored for completion. 6. The Executive Director will oversee the implementation of any corrective actions identified throughout the QAPI process to ensure sustained improvement acroess departments.

OAR 411-054-0025 (9) Facility Administration: Quality Improvement (9) QUALITY IMPROVEMENT PROGRAM. The facility must develop and conduct an ongoing quality improvement program that evaluates services, resident outcomes, and resident satisfaction. 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 notify the local Senior and People with Disabilities (SPD) office when an incident of abuse, or suspected abuse, occurred and failed to immediately report physical injuries of unknown cause to the local SPD office as suspected abuse, unless an immediate facility investigation reasonably concluded and documented the physical injury was not the result of abuse, for 2 of 3 residents with reportable incidents (#s 1 and 2). Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 04/2025 with diagnoses including dysphagia and left hemiplegia following cerebral infarction (stroke) and vascular dementia. The resident's 04/07/25 through 04/28/25 progress notes, temporary service plans, incident reports, and investigations were reviewed, and interviews with staff were conducted. The following was identified: * On 4/17/25, a progress note stated Resident 1 reported s/he gave money to a caregiver to buy cigarettes for the resident and the caregiver took the money but did not buy him/her any cigarettes. On 04/29/25, Staff 1 (Regional Director of Operations) confirmed that the incident was not investigated or reported to the local SPD office. At survey request, the incident was reported, and confirmation was provided on 04/29/25. * On 04/21/25, Resident 1 was being escorted from his/her shower to the bedroom when the chair the resident was seated in became stuck on the threshold between the rooms. The incident report stated the caregiver used force to get the chair over the threshold “causing the resident to hit [his/her] head on the door frame and fall out of [his/her] shower chair on the floor, sustaining left shoulder pain.” The resident was sent to the hospital and returned with a diagnosis of left shoulder fracture. The investigation did not include all required components, including documentation of individuals present. The incident was not reported immediately to the local SPD office. The facility provided documentation that the incident was reported to the local SPD office on 04/25/25. The need to ensure all incidents of abuse or suspected abuse were immediately reported to the local SPD office and investigations included all required components was reviewed with Staff 1 and Staff 2 (Regional Nurse Consultant) on 05/01/25 at 10:20 am. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 06/2021 with diagnoses including displaced fracture of right femur, protein-calorie malnutrition, and macular degeneration. During the acuity interview on 04/28/25, the resident was identified as requiring a high level of care from staff, and his/her service plan stated the resident needed assistance with all ADL cares, including showering. The resident's 01/28/25 through 04/28/25 progress notes, skin monitoring shower review sheets, temporary service plans, incident reports, and investigations were reviewed, and interviews with staff were conducted. The following was identified: On 03/26/25, bruising to the resident’s right forearm was noted on his/her skin monitoring shower review sheet. Staff 1 (Regional Director of Operations) confirmed on 04/29/25 that there was no documented evidence of the cause of the bruise, an investigation to rule out abuse did not immediately occur, and the incident was not immediately reported to the local SPD office. The survey team requested that the incident be reported to the local SPD office, and Staff 1 provided confirmation that it was reported on 04/29/25. The need to ensure all injuries of unknown cause were immediately reported to the local SPD, unless an immediate investigation reasonably concluded that the injury was not the result of abuse, was reviewed with Staff 1 and Staff 2 (Regional Nurse Consultant) on 05/01/25 at 10:20 am. They acknowledged the findings.

1. Training of the Clinical Team: The RCC, SSD, LN and ED will complete focused training on incident reporting, investigation procedures, and how to proberly evalute and rule out abuse and neglect. 2. All staff Education: All staff will complete Relias training on Elder Abuse and Neglect. In addition, in-person education will be provided to all staff on recognizing and reportinging abuse and neglect. RCC, SSD, LN's and Med-Techs will receive specialized in-person training on how to complete incident reports anc contuct investigations. 3. The RCC's, SSD LN's and ED will review each icident daily and weekly and contuct thorough investigations. If abuse or neglect can not be ruled out, The Executive Director will report the incident to the local APS office. 4. The Executive Director will monitor incidents Monday-through Friday at least 3x a week to ensure that all abuse the neglect to ensure on going proper abuse and neglect.

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 changes and entries made to the service plan were dated and initialed, service plans were reflective of residents' needs, provided clear direction to staff regarding the delivery of services, and service plans were implemented for 6 of 7 sampled residents (#s 1, 2, 3, 4, 5, and 7) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 04/2025 with diagnoses including dysphagia and left hemiplegia following cerebral infarction (stroke) and vascular dementia. The resident's current service plan available to staff, dated 04/09/25, and 04/07/25 through 04/28/25 temporary service plans and progress notes were reviewed, interviews with staff and the resident were conducted, and observations of the resident were completed. The resident's service plan was not reflective of current needs and/or did not provide clear direction to staff in the following areas: * Pet care; * Number of staff required for transfers; * Toileting; * Pain including nonpharmacological interventions; and * Use of side rails, including safety checks and who to notify if a problem was identified. The need to ensure service plans were reflective of the resident’s current status and care needs and provided clear direction to staff was reviewed with Staff 1 (Regional Director of Operations) and Staff 2 (Regional Nurse Consultant) on 05/01/25 at 10:20 am. They acknowledged the findings. ?2. Resident 4 was admitted to the facility in 06/2021 with diagnoses including displaced fracture of right femur, protein-calorie malnutrition, and macular degeneration. The resident's current service plan available to staff, dated 03/24/25, and 01/28/25 through 04/28/25 temporary service plans and progress notes were reviewed, interviews with staff and the resident were conducted, and observations of the resident were completed. The resident's service plan was not reflective of current needs and/or did not provide clear direction to staff in the following areas: * Evacuation assistance due to being wheelchair bound and living on the second floor; * Safety checks; * Vision impairment; * Pet care; * Personal shopping; * Bathing; * Dressing and clothing preferences; * TED hose; * Mobility and assistance required; and * Wheelchair preferences including removal of right armrest and left leg rest. The need to ensure service plans were reflective, provided clear direction to staff, and were implemented was reviewed with reviewed with Staff 1 (Regional Director of Operations) and Staff 2 (Regional Nurse Consultant) on 05/01/25 at 10:20 am. They acknowledged the findings. 3. Resident 2 was admitted to the facility in 11/2023 with diagnoses including Type 2 diabetes mellitus and psychotic disturbance. Observations of the resident, interviews with resident and staff, review of the resident's most recent service plan, dated 01/27/25, and temporary service plans (TSPs) showed the service plan was not reflective of the resident's current care needs, was not implemented, and/or did not provide clear direction to staff in the following areas: * Bathing, including location and number of staff required; * Use of side rails, including safety checks and who to notify if a problem was identified; * Removing sharp objects from room to avoid self-harm behaviors; and * Wound care including who provided dressing changes when identified as soiled. The need to ensure resident service plans were reflective of current care needs, were consistently implemented, and provided clear direction to staff was discussed with Staff 1 (Regional Director of Operations) and Staff 2 (Regional Nurse Consultant) on 05/01/25 at 11:25 am. They acknowledged the findings. 4. Resident 7 was admitted to the facility in 02/2024 with diagnoses including incomplete quadriplegia and blindness in left eye. Observations and interviews with the resident and review of the resident's most recent service plan, dated 02/25/25, showed the service plan did not provide clear direction to staff in the following areas: * Preferences including emptying his/her urinal first prior to providing any additional care assistance; and * Sanitizing items touched in the bathroom following toileting. The need to ensure resident service plans provided clear direction to staff was discussed with Staff 1 (Regional Director of Operations) and Staff 2 (Regional Nurse Consultant) on 05/01/25 at 11:25 am. They acknowledged the findings. 5. Resident 3 moved into the facility in 10/2023 with diagnoses including Parkinson’s disease and muscle weakness. Observations of the resident, interviews with resident and staff, review of the resident's service plan, dated 04/02/25, and progress notes, dated 01/28/25 to 04/28/25, were completed. The resident's service plan was not reflective and/or did not provide clear direction to staff in the following areas: * Use of side rails, including safety checks, when to position up and down, and who to notify if a problem was identified; * Ability and assistance required to buckle or release seat belt of reclining manual wheelchair; * Assistance with and location for toileting tasks; * Frequency of brief checks; and * Assistance required with meals, including drinking and feeding. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Regional Director of Operations) and Staff 2 (Regional Nurse Consultant) on 04/30/25 at 2:20 pm. The findings were acknowledged. 6. Resident 5 moved into the facility in 04/2025 with diagnoses including Type 2 diabetes, hypertension, and dependence on renal dialysis. Observations of the resident, interviews with the resident and staff, review of the resident's service plan, dated 02/05/25, and progress notes, dated 01/28/25 to 04/28/25, were completed. The resident's service plan was not reflective and/or did not provide clear direction to staff in the following areas: * Use of side rails, including safety checks, when to position up and down, and who to notify if a problem was identified; * Assistance required with transfers, laundry, and showers; * Pain, including pharmaceutical and non-pharmaceutical interventions; and * Ability to transfer to the toilet in the bathroom. The need to ensure service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Regional Director of Operations) and Staff 2 (Regional Nurse Consultant) on 04/30/25 at 2:35 pm. The findings were acknowledged.

1. The RCC, Social Service, LN and Executive Director will complete a full aduit of all resident care plans to esure they contain complete, up-to-date, and accurate information refeclting each residents needs and preferances. Resident 1,2,3,4,5, and 7 were fully audited and TSP's are in place for additional service plan information. 2. The RCC will audit care plan binders to comfirm that all most current and up todate care plans are readily accessible to staff at all times. 3. The RCC, SSD and LN nurse will hold a care confernece for each resident in the community. During the care confernce they will review any changes, concerns from the last 90 days and update acordingly to refeclt the needs and resident preferences. 4. The RCC and SSD will comlete Relias training on care planning, followed by in-person training to ensure thorough understanding and application of care planning best practices. 5. The Executive Director will review all services plans following 30-day, 60-day, and 90-day reviews to verify accuracy and compliance with reguatory and facility standards.

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 which 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 to the resident for 5 of 6 sampled residents (#s 1, 2, 4, 5, and 6) whose service plans were reviewed. Findings include, but are not limited to: Resident 1, 2, 4, 5, and 6’s most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans. During an interview on 04/30/25 at 1:20 pm, Staff 1 (Regional Director of Operations) confirmed the facility lacked documented evidence of a Service Planning Team for all residents. The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 and Staff 2 (Regional Nurse Consultant) on 05/01/25 at 10:20 am. They acknowledged the findings.

1.The facility will implement a dedicated service planning team composed of the SSD, RCC LN. 2.The SSD will be responsible for scheduling all resident care conferences. Upon scheduling, the SSD will notify the Mediciad case manager, Family members, or the residents POA. 3. After each care conference is completed, the updated care plan will be signed by all staff memebers who attended the meeting. In additon, care staff will review and sign care plans to comfirm their understanding of the residents needs and prefernces. 4. The Executive Director will review all care conferences scheules and check in with staff after the meetings to ensure all components have been completed and documented accuratley.

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 residents who had a significant change of condition were evaluated, referred to the RN for assessment, and the service plan was updated as needed, and/or failed to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff on all shifts, and document weekly progress until the condition resolved for 4 of 6 sampled residents (#s 1, 2, 4, and 5) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 11/2023 with diagnoses including Type 2 diabetes mellitus and psychotic disturbance. The resident's current service plan dated 01/27/25, temporary service plans, the 04/01/25 through 04/28/25 MAR, and 03/09/25 to 04/28/25 progress notes were reviewed. Observations of the resident and interviews with caregivers were completed between 04/29/25 and 05/01/25. The resident experienced multiple short-term changes of condition as outlined: a. The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and progress noted at least weekly through resolution: * 04/22/25 – Resident did not receive his/her routine insulin; and * 04/23/25 – Resident did not receive his/her routine insulin. b. The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts: * 03/12/25 – Redness with shearing to the coccyx. The need to ensure resident-specific actions or interventions for short-term changes of condition were determined, documented, communicated to staff on each shift, and the changes of condition were monitored at least weekly through resolution was discussed with Staff 1 (Regional Director of Operations) and Staff 2 (Regional Nurse Consultant) on 05/01/25 at 11:25 am. They acknowledged the findings. ?2. Resident 1 was admitted to the facility in 04/2025 with diagnoses including dysphagia and left hemiplegia following cerebral infarction (stroke) and vascular dementia. The resident's most recent evaluation and service plan, dated 04/09/25, and 04/07/25 through 04/27/25 temporary service plans, progress notes, and skin monitoring sheets were reviewed, and interviews with staff were conducted. The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and/or monitoring, with progress noted at least weekly, through resolution: * 04/19/25 – Assisted to ground by care staff due to difficulty using transfer pole; * 04/19/25 – Blisters on right low back; and * 04/20/25 – Loose stools. The need to ensure the facility determined and documented what action or interventions were needed for short-term changes of condition, communicated the interventions to staff on all shifts, and monitored the short-term changes of condition, with progress noted at least weekly, through resolution was reviewed with Staff 1 (Regional Director of Operations) and Staff 2 (Regional Nurse Consultant) on 05/01/25 at 10:20 am. They acknowledged the findings. 3. Resident 4 was admitted to the facility in 06/2021 with diagnoses including displaced fracture of right femur, protein-calorie malnutrition and macular degeneration. The resident's most recent evaluation and service plan, dated 03/24/25, and 01/28/25 through 04/28/25 temporary services plans, progress notes, and skin monitoring shower notes were reviewed, interviews with staff and the resident were conducted, and observations of the resident were completed. The following was identified: a. On 04/02/25, the resident was documented as weighing 126.2 pounds. His/her last recorded weight, on 01/05/25, was 138.6 pounds. This was a loss of 12.2 pounds, or 11.2% of his/her total body weight, in three months and constituted a significant change of condition. There was no documented evidence that the facility evaluated the resident, referred to the facility RN for assessment, or updated the service plan. In an interview at 8:59 am on 05/01/25, a MT confirmed that after the weight was recorded in the MAR no additional steps were taken to evaluate the resident or refer to the facility RN. The MT stated the facility’s process is that the RN will review the weights when they are able to. Refer to C280. b. The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and/or monitoring at least weekly through resolution: * 03/26/25 – Bruising on right forearm and rash on lower back; * 03/27/25 – New medications; * 04/02/25 – Left upper thigh “excoriation”; * 04/07/25 – New medication; * 04/09/25 – Rash on right upper thigh; * 04/09/25 – Scratches on right shoulder and right lower back; * 04/18/25 – Bronchitis and new medication; and * 04/19/25 – Loose stools. The need to ensure the facility evaluated residents who experienced significant changes of condition, referred the resident to the facility nurse, documented the change and updated the service plan as needed; and determined and documented what action or interventions were needed for short-term changes of condition, communicated the interventions to staff on all shifts, and monitored the short-term changes of condition at least weekly through resolution was reviewed with Staff 1 (Regional Director of Operations) and Staff 2 (Regional Nurse Consultant) on 05/01/25 at 10:20 am. They acknowledged the findings. 4. Resident 5 was admitted to the facility in 04/2025 with diagnoses including Type 2 diabetes, hypertension, and dependence on renal dialysis. The resident's current service plan, dated 02/05/25, temporary service plans, progress notes dated 01/28/25 through 04/28/25, and corresponding incident reports were reviewed. Observations of the resident and interviews with caregivers were completed between 04/28/25 and 04/30/25. The following short-term change of condition lacked documentation of progress, at least weekly, through resolution: * 04/07/25 – Bloody nose. The need to ensure actions or interventions for short-term changes of condition were monitored, at least weekly, through resolution was discussed with Staff 1 (Regional Director of Operations) and Staff 2 (Regional Nurse Consultant) on 04/30/25 at 2:35 pm. The findings were acknowledged.

1. The RN will complete the OHCA Role of the Nurse in community base care to ensure full understanding of their responsibilites. Residents 1,2, 4, and 5 were fully audited, service plans were updated, and all information in the nursing assessments are acurate. 2. During daily stand-up the RN, LN, SSD, RCC and ED will reivew all alerts, TSP's, IR's and relevant progress notes to ensure proper follow-up and documentation. 3. A chart audit will be conducted for all residents who experienced a change in condittion in the last 30-days. This task will be divided aming the LPN's and RN. Any concerns will be addressed immediately, with documentation and follow-up completed as needed. 4. The RN will maintain a Change of Condition Log. The COC log will be reviewed each morning during the stand-up meeting to ensure timely responses and accountabiliy. 5. Clinical staff will monitor compliance daily, Exectuive director will conduct additional oversight bi-weekly to ensure compliance.

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 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed in a timely manner and documented findings, resident status, and interventions made as a result of the assessment for 2 of 5 sampled residents (#s 1 and 4) who experienced significant changes of condition. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 04/2025 with diagnoses including dysphagia and left hemiplegia following cerebral infarction (stroke) and vascular dementia. The resident's current service plan available to staff, dated 04/09/25, and temporary service plans and progress from 04/07/25 through 04/27/25 were reviewed, and interviews with staff were conducted. The resident’s service plan stated the resident was able to transfer at times with one person assist using a transfer pole, could utilize the toilet for bowel and bladder needs with one person assisting, dressed with assistance from one care staff and use of the transfer pole, and was escorted by staff to meals in the dining room. On 04/21/25 Resident 1 experienced a fall from his/her wheelchair and returned from the hospital on 04/22/25 with a diagnosis of left humerus (shoulder) fracture. The resident required an increase in assistance with ADL care including dressing, due to his/her arm being in a sling, and was noted as being unable to transfer out of bed, requiring increased assistance with in-bed personal cares, and needing meals served in his/her room. On 04/22/25 an RN note documented changes to the resident’s service plan to include use of a sling, ice, and pain medication. There was no documented evidence that a significant change of condition assessment and appropriate service plan updates occurred to address the resident’s changes in ADL care and level of assistance required. The need to ensure all significant changes of condition were assessed by an RN and included findings, resident status, and interventions made as a result of the assessment was reviewed with Staff 1 (Regional Director of Operations) and Staff 2 (Regional Nurse Consultant) on 05/01/25 at 10:20 am. They acknowledged the findings. 2.?Resident 4 was admitted to the facility in 06/2021 with diagnoses including displaced fracture of right femur, protein-calorie malnutrition and macular degeneration. The resident's most recent evaluation and service plan, dated 03/24/25, and 01/28/25 through 04/28/25 temporary services plans, progress notes, and skin monitoring shower notes were reviewed, interviews with staff and the resident were conducted, and observations of the resident were completed. The following was identified: The resident’s weight records were documented as follows: * 01/05/25 – 138.6 pounds; and * 04/02/25 – 126.2 pounds. Between 01/05/25 and 04/02/25 the resident experienced a severe weight loss of 12.4 pounds, or 11.2% of his/her total body weight. There was no documented evidence that an RN completed a significant change of condition assessment which documented findings, resident status, and interventions made as a result of the assessment. At the time of survey on 04/29/25 at 3:16 pm, the resident weighed 125.6 pounds. The resident was identified as eating all meals in his/her room and being independent with eating. During an interview on 04/28/25 at 2:35 pm, the resident stated s/he had not been eating well recently due to not liking the food and feeling that it was too hard to chew at times. The need to ensure all significant changes of condition were assessed by an RN, including documenting findings, resident status, and interventions made as a result of the assessment, was reviewed with Staff 1 (Regional Director of Operations) and Staff 2 (Regional Nurse Consultant) on 05/01/25 at 10:20 am. They acknowledged the findings.

1. The facility RN will conduct weekly audits of health serivces, including change of condition follow-up, charting accuracy, prognote reviews, IRS and TSP's The RN will monitor vital signs including weights monthly to ensure all change of conditions are completed. All weights will be completed by the care staff and reported to the RN who will review weights and request re-weights as needed. Once weights are entered by the RN they will complete a weight report and start a change of condition it is needed. Resident 1 and 4 were reweighed and audited, appropriate nutritional documentation is in place at this time. 2. All Med-tech, LN and caregivers will complete in-person and relias training that includes how to idenify and monitor change of condition and who to notify 3. Daily and weekly clincal review including, IR's, TSP, and any other clincial concerns will completed.Once we have idifed a change of constioton the RN will completed all needed assesments. 5. RN will complete a Change of Condidtion log and it will be reviewed daily. 6. On going monitoring will be conducted bi weekely m The Executive Director will be responible to the over-sight and follow-through.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by:

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure staff were informed of new interventions, and the service plan was adjusted if necessary, for 1 of 3 sampled residents (# 2) who received outside services. Findings include, but are not limited to: Resident 2 was admitted to the facility in 11/2023 with diagnoses including Type 2 diabetes mellitus and psychotic disturbance. Progress notes, dated 03/09/25 to 04/28/25, outside agency services notes, dated 03/15/25 to 04/21/25, and the service plan, dated 01/27/25, were reviewed, and interviews with the resident, staff, and home health nurse were conducted. There was no documented evidence staff were informed of the new instructions and the service plan was updated for the following recommendations: * 03/27/25 - HH RN note stated, “Pt [patient] reports no dressing in place to wound on NOC [night shift]. Please ensure staff keeps dressing on for protection and healing”; * 04/10/25 – HH RN note stated, “Pt [patient] to increase water intake…”; * 04/14/25 – HH RN note stated “…increase hydration”; and * 04/18/25 – HH RN note included instructions for pressure relief that included “…tilt in powerchair.” The need to ensure staff were informed of new interventions and the service plan was adjusted as necessary after on-site health services were provided was discussed with Staff 1 (Regional Director of Operations) and Staff 2 (Regional Nurse Consultant) on 05/01/25 at 11:25 am. They acknowledged the findings.

1. All staff will receive education and training on the role of the outside providers, including Home Health and how they intreact with and support resident care within the community.Resident 2 outside provider notes were audited, and recommendations are in place on TSP. 2. Home Health provders will be required to check in at the front desk upon arrival and complete the designated outside provider form to document their visit provided. 3. Once completed, the home health forms will submitted to the RCC or LN for Review 4. The RCC or LN will asses the Home Health note and implement any necessary intervention, such as initiating a TSP. 5. afer the interventions are signed off, the information will be brought to the daily stand-up meeting for review and sucussion with the clinical team to ensure coodinated care. 6. The Executive Director will review the process and documention 2x weekly to ensure accuracu, completeness and and timely implemtation of any needed interventions.

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by:

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to follow established infection prevention and control protocols to ensure a safe, sanitary, and comfortable environment for 2 of 2 sampled residents (#s 2 and 3) whose ADL care was observed. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 10/2023 with diagnoses including Parkinson’s disease and muscle weakness. A review of his/her current service plan and interviews with staff revealed s/he was dependent on two staff for toileting tasks to be performed with a mechanical lift transfer in and out of bed. On 04/29/25 at 11:15 am, the surveyor observed two staff provide incontinence care for Resident 5 while s/he was in bed. Both staff had already donned gloves prior to surveyor’s arrival, and the resident was lying on his/her back. The soiled brief was removed by one CG and thrown into a trash receptacle. The resident was rolled to one side, and the caregiver then placed a clean brief without performing hand hygiene or a glove change. The resident was then rolled to the opposite side and additional perineal care was performed along with adjusting the clean brief and placing shorts. The caregivers assisted the resident to his/her back. After the clothes were adjusted, both staff doffed gloves without performing hand hygiene and were observed touching the resident’s sheets, blanket, pillows, wheelchair, draw sheet, mechanical lift, and sling. The need to ensure infection prevention and control protocols were followed was discussed with Staff 1 (Regional Director of Operations) and Staff 2 (Regional Nurse Consultant) on 04/30/25 at 2:35 pm. The findings were acknowledged. ?2. Resident 2 was admitted to the facility in 11/2023 with diagnoses including Type 2 diabetes mellitus and psychotic disturbance. A review of his/her current service plan and interviews with staff revealed s/he was dependent on staff for toileting tasks and required a two-person assist with incontinence care in bed. The resident had stage 2 pressure ulcers identified on his/her sacrum and left gluteal fold and additional unstageable wounds on the right and left buttocks. S/he required a mechanical lift for transfer in and out of bed. On 04/30/25 at 9:57 am, the surveyor observed Staff 12 (CG), Staff 15 (CG), and Staff 23 (CG) provide incontinence care for Resident 2 in bed. No hand hygiene was observed prior to staff donning gloves. Staff 12 and Staff 15 removed the dirty brief, the resident was rolled to one side, and then Staff 15 applied the clean brief. Resident 2 had a bowel movement after being rolled and Staff 15 cleaned the perineal area with wipes. Staff 15 identified the dressings on his/her wounds were soiled from the bowel movement and needed to be replaced. Staff 15 changed his/her gloves prior to the dressing change but no hand hygiene was observed prior to donning clean gloves. Staff 15 applied barrier cream to his/her buttocks and dressings were applied to multiple wounds. No hand hygiene or glove change was observed prior to applying the dressings. Caregivers removed a blanket from underneath the resident, observed to have had brown and red stains on it, and did not bag the stained blanket prior to tossing it on the floor. The dirty brief was removed and tossed in the trash can and a second clean brief put in place. The caregivers assisted the resident to his/her back, donned pants and moon boots, then rolled him/her to each side to adjust the pants and shirt. After the clothes were adjusted, all staff doffed gloves without performing hand hygiene and were observed touching the resident’s sheets, blanket, pillows, wheelchair, draw sheet, mechanical lift, and sling without performing hand hygiene. The need to ensure infection prevention and control protocols were followed was discussed with Staff 1 (Regional Director of Operations) and Staff 2 (Regional Nurse Consultant) on 05/01/25 at 11:25 am. They acknowledged the findings.

The facility will conduck in-person infection control training for all staff to reinforce current infection prevention policies and procedures. 2. supplemental Hand Hygiene and infection control best practices will be provided to ensure staff consistenly apply proper rechniques during care delivery. 3. The LN, RCC and ED will perform routine check throughout the weke to monitor staff afherence to proper hand hygiene protocolsm especially during care and meal servies. 4. LN, RCC and ED will contuine on-going observations and monitoring for compliance.

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments (1) MEDICATION AND TREATMENT ADMINISTRATION SYSTEMS. The facility must have safe medication and treatment administration systems in place that are approved by a pharmacist consultant, registered nurse, or physician.(a) The administrator is responsible for ensuring adequate professional oversight of the medication and treatment administration system. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure a safe medication and treatment administration system. Findings include, but are not limited to: During the re-licensure survey, conducted 04/28/25 through 05/01/25, professional oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas: * C302 - Tracking Controlled Substances; * C303 - Medication and Treatment Orders; * C305 - Resident Right to Refuse; and * C310 - Medication Administration. The need to ensure a safe medication and treatment system was discussed with Staff 1 (Regional Director of Operations) and Staff 2 (Regional Nurse Consultant) on 05/01/25 at 1:00 pm. The findings were acknowledged.

PLease refer to the plans of correction for C302, C303, C305, and C310.

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments (1) MEDICATION AND TREATMENT ADMINISTRATION SYSTEMS. The facility must have safe medication and treatment administration systems in place that are approved by a pharmacist consultant, registered nurse, or physician.(a) The administrator is responsible for ensuring adequate professional oversight of the medication and treatment administration system. 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 accurately tracking controlled substances administered by the facility for 3 of 3 sampled residents (#s 1, 4 and 5) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 04/2025 with diagnoses including dysphagia and left hemiplegia following cerebral infarction (stroke) and vascular dementia. The resident sustained a left shoulder fracture on 04/21/25. The resident had a signed physician order for PRN oxycodone (for pain), 10 mg tablet, to be administered every four hours as needed. Oxycodone is a narcotic pain medication and a controlled substance. Review of the resident's 04/07/25 through 04/28/25 MAR and Controlled Substance Disposition log revealed the following: a. On 04/18/25 at 10:44 pm, oxycodone was documented as administered on the MAR but was not documented in the Controlled Substance Disposition log. b. On the following dates, oxycodone was documented in the Controlled Substance Disposition log, but was not documented as administered on the MAR: * 04/09/25 at 5:20 am; * 04/19/25 at 10:42 am; * 04/21/25 at 7:49 am; and * 04/21/25 at 5:00 pm. c. On 04/21/25, oxycodone was documented as having been administered in the Controlled Substance Disposition log with less than four hours between doses. During an interview on 04/30/25 at 1:20 pm, Staff 1 (Regional Director of Operations) stated that due to recent changes to staffing, she was unaware of whether there was a current system in place for reviewing or tracking controlled substances. The need to ensure a system was in place for accurately tracking controlled substance distribution was reviewed with Staff 1 and Staff 2 (Regional Nurse Consultant) on 05/01/25 at 10:20 am. They acknowledged the findings. ?2. Resident 4 was admitted to the facility in 06/2021 with diagnoses including displaced fracture of right femur, protein-calorie malnutrition and macular degeneration. The resident had a signed physician order for tramadol (for pain), 50 mg, to be administered twice per day as needed. Tramadol is a narcotic pain medication and a controlled substance. Review of the resident's 04/01/25 through 04/28/25 MAR and Controlled Substance Disposition logs revealed the following: On 04/06/25, tramadol was documented in the Controlled Substance Disposition log, but was not documented as administered on the MAR. During an interview on 04/30/25 at 1:20 pm Staff 1 (Regional Director of Operations) stated that due to recent changes in staffing, she was unaware of whether there was a current system in place for reviewing or tracking controlled substances. The need to ensure a system was in place for accurately tracking controlled substance distribution was reviewed with Staff 1 and Staff 2 (Regional Nurse Consultant) on 05/01/25 at 10:20 am. They acknowledged the findings. 3. Resident 5 moved into the facility in 04/2025 with diagnoses including Type 2 diabetes, hypertension, and dependence on renal dialysis. The resident's 04/01/25 through 04/28/25 MAR, current physician orders, and Controlled Substance Disposition log entries were reviewed. The following was identified: The resident had a physician order for hydrocodone/APAP (a pain reliever) 5-325 mg one tablet by mouth three times daily as needed. Three entries were documented in the Controlled Substance Disposition log, but not on the resident's MAR: * 04/11/25 at 9:06 am; * 04/13/25 at 6:47 am; and * 04/17/25 at 8:29 pm. The need to ensure the facility had a system for tracking controlled substances was discussed with Staff 1 (Regional Director of Operations) and Staff 2 (Regional Nurse Consultant) on 04/30/25 at 2:40 pm. The findings were acknowledged.

1. The RCC and Med-techs will receive in-depth training on proper ordering and tracking of medication. documentation of controlled susstances, residents rights, including right to refuse. Resident, 1,4, and 5 MARS were audited, missing documentaion was fixed, staff have been trained on the process moving forward. 2. Training will be provied to RCC, Med-techs and LN specifically on tracking and documention of controlled to ensure regulatory compliace. 3. RCC will perform daily audits of the medication room to verify that all controlled substances are accuratley documented in both the NARC book and the MAR. 4. The RN and ED will join the RCC in conducting Bi-weekly audits of the med-room for accutacy, accountability, and consisent practices across all shifts. 5. The RN,RCC and ED will complete a full aduit of residents MAR and Narc Book and review with Med-techs and ensure they have completed their missed documentation for the narcs that were signed out of the book but not the MAR. 9. On-going complaince will be overseen by the Executive Director and adress any patterns or concerns with staff.

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)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review it was determined the facility failed to ensure treatment orders were carried out as prescribed and failed to ensure written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all treatments the facility was responsible to administer for 3 of 6 sampled residents (#s 1, 2, and 5) whose treatment orders were reviewed. Findings include, but are not limited to: Resident 1 was admitted to the facility in 04/2025 with diagnoses including dysphagia and left hemiplegia following cerebral infarction (stroke) and vascular dementia. Resident 1's physician's orders, MAR and progress notes dated 04/07/25 through 04/28/25 were reviewed, and the following was identified: a. The resident had an order dated 04/18/25 for blood pressure to be monitored each shift for one week, and results were to be faxed to the physician. There was no documented evidence that blood pressure monitoring occurred and was communicated to the physician as ordered. b. The resident had an order dated 04/18/25 for oxygen saturation to be monitored each shift for two weeks and results were to be faxed to the physician. There was no documented evidence that oxygen saturation monitoring occurred. c. The resident had an order dated 04/18/25 for metoprolol (for hypertension) to be administered two times per day. The order stated to hold the medication if the resident’s heart rate was less than 60 beats per minute. In an interview on 04/30/25 at 1:25 pm, Staff 1 (Regional Director of Operations) and Staff 2 (Regional Nurse Consultant) confirmed that there was no documented evidence that staff were monitoring the resident’s heart rate prior to administering the medication. d. On 04/18/25, a signed physician’s order stated “Keep Narcan spray readily available for opioid overdose.” In an interview on 4/30/25 at 3:05 pm, Staff 2 confirmed the facility did not have Narcan available for the resident. e. The resident had signed orders dated 04/18/25 for the following medications which were not on the MAR: * Melatonin (for insomnia); and * Calcium carbonate (for heartburn). The need to ensure all orders were carried out as prescribed was reviewed with Staff 1 and Staff 2 on 05/01/25 at 10:20 am. They acknowledged the findings. 2. Resident 5 moved into the facility in 04/2024 with diagnoses including Type 2 diabetes, hypertension, and dependence on renal dialysis. Resident 5’s current physician orders, progress notes dated 01/28/25 through 04/28/25, and MAR dated 04/01/25 through 04/28/25, revealed the following: a. The following medications and treatments were listed as “Hold” or “Other:” * Lactulose (for bowel care) on two occasions; * Levetiracetam (for unspecified convulsions) on one occasion; * Lokelma (for hyperkalemia [high potassium]) on 13 occasions; * Senna (for bowel care) on one occasion; * Vital signs and weight on one occasion; * Azelastine eye drop on one occasion; * Velphoro (for kidney disease) on one occasion; * Gabapentin (for peripheral vascular disease) on 11 occasions; * Routine humalog (for diabetes) on 25 occasions; * Humalog sliding scale (for diabetes) on 15 occasions; * Hydralazine (for high blood pressure) on 11 occasions; and * Sevelamer (for dialysis) HCL on 11 occasions. During an interview on 04/30/25 at 11:25 am, Staff 5 (LPN) stated most of the occurrences were when the resident was at dialysis. She confirmed there was no prescriber order for which medicines to hold and which medicines to administer when the resident was outside of the facility while at dialysis. b. The resident had an order, dated 03/04/25, for blood sugar to be monitored during administration of routine insulin, which was administered three times daily. The order stated, “Hold if CBG under 100; Give 4 units at meals plus sliding scale; Notify RN if over 400 or under 80; If under 80 give juice and a snack; Notify MD if under 60.” On 04/10/25 at 8:00 am and 04/12/25 at 12:00 pm, the resident’s blood sugar was above 400. On 04/30/25 at 11:25 am, Staff 5 confirmed there was no documented evidence the RN was notified. Additionally, the Humalog was marked as “no insulin required” on the following dates: * 04/04/25 at 8:00 am, when CBG was 110; * 04/11/25 at 12:00 pm, when CBG was 120; and * 04/14/25 at 8:00 am, when CBG was 149. During an interview on 04/30/25 at 11:25 am, Staff 5 confirmed the routine insulin should have been administered on the above dates. The need to ensure all orders were carried out as prescribed was reviewed with Staff 1 (Regional Director of Operations) and Staff 2 (Regional Nurse Consultant) on 04/30/25 at 2:35 pm. They acknowledged the findings. 3. Resident 2 was admitted to the facility in 11/2023 with diagnoses including Type 2 diabetes mellitus and psychotic disturbance. The resident's 04/01/25 to 04/28/25 MARs and physician orders dated 03/07/25 were reviewed. The following was identified: a. The resident had orders for: * Polyethylene glycol powder 17 grams in 4-8 ounces of fluid everyday PRN for constipation; and * Senna 8.6 mg, two tablets PRN for constipation. In an interview with Staff 22 (MT) on 04/30/25 at 12:15 pm, she was not aware Resident 2 had these two bowel medications. She opened the drawers to the medication cart and could not locate either of the two medications. In an interview with Staff 5 (LPN) on 05/01/25 at 10:02 am, she confirmed the medications were not available and stated she would order them. b. A physician order indicated “In the event that vital signs are outside of parameters, facility LN will be notified; Resident will be placed on 48-hour monitoring or per LN direction.” Weight parameters included a decrease or increase of five pounds or more in one week and a decrease or increase of 10 pounds in one month. Weight records indicated following: * 03/11/25: 222.2 pounds; and * 03/18/25: 204 pounds. Resident 2 lost 18.2 pounds between 03/11/25 and 03/18/25, a loss of more than five pounds in one week. In an interview with Staff 22 (MT) on 04/30/25 at 12:15 pm, she indicated weights are usually taken by the caregivers, communicated to MT’s, and then entered into the resident’s record. The nurses looked at the weights after they were entered, but she said she was not responsible for reporting the weights to the nurses. In an interview with Staff 5 (LPN) on 05/01/25 at 10:02 am, she acknowledged the resident should have been monitored for weight loss greater than 5 pounds in one week. There was no documented evidence the physician instructions were followed, which included notifying the nurse and monitoring the resident for 48 hours. The need to ensure all orders were carried out as prescribed was reviewed with Staff 1 (Regional Director of Operations) and Staff 2 (Regional Nurse Consultant) on 05/01/25 at 11:25 am. They acknowledged the findings.

1. The LN and RN will coduct a comptrhensive audit of all the residents treatment records weekly to ensure that all ordered treatments are being performed and accutatlely documented. Resident 1, 2, and 5 were fully audited, MARS were cleaned up,Treatments, were audited for clear paramenters. staff have received training at this time. RCC Audits are now back in place and completed weekly. 2. All clinical staff will receive in-service education on treatment protocols and documentiation standards, and the importance of complaince with physician orders. This in-service is required for all imcoming and currenly employee's. 3. To maintain ongoing complaince the nursing staff will perform weekly audits and monthly audits for contuined over-sight

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

OAR 411-054-0055 (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/practitioner if a resident refused consent to an order for 2 of 6 sampled residents (#s 4 and 5) who had documented medication refusals. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 04/2025 with diagnoses including Type 2 diabetes, hypertension, and dependence on renal dialysis. The resident's MAR, dated 04/01/25 through 04/28/25, was reviewed and revealed facility staff documented Resident 5 refused the following orders: * Lactulose (for bowel care) on 17 occasions; * Lokelma (for hyperkalemia) on five occasions; and * Senna on (for constipation) on 11 occasions. The resident had a signed practitioner’s order from 04/03/24 to “Notify PCP [primary care physician] of missed: at time of missed med, do not notify, or other frequency (please specify).” However, the areas were blank on which option the practitioner preferred for missed medications. On 04/30/25 at 11:21 am, Staff 5 (LPN) confirmed there was no documented evidence the facility notified Resident 5's physician of the refusals. The need to notify the physician or other practitioner when a resident refused consent to an order was discussed with Staff 1 (Regional Director of Operations) and Staff 2 (Regional Nurse Consultant) on 04/30/25 at 2:40 pm. The findings were acknowledged. ?2. Resident 4 was admitted to the facility in 06/2021 with diagnoses including displaced fracture of right femur, protein-calorie malnutrition and macular degeneration. The resident's MAR, dated 04/01/25 through 04/28/25, was reviewed and revealed facility staff documented Resident 4 refused the following orders: * Melatonin (for insomnia) on 13 occasions; * Senna/docusate (for bowel management) on 10 occasions; * Brimonidine/timol eye drops (for glaucoma) on one occasion; and * Eliquis (for atrial fibrillation) on one occasion. On 05/01/25 at 10:20 am Staff 2 (Regional Nurse Consultant) confirmed there was no documented evidence the facility notified Resident 4’s physician of the refusals. The need to notify the physician or other practitioner when a resident refused to consent to an order was reviewed with Staff 1 (Regional Director of Operations) and Staff 2 on 05/01/25 at 10:20 am. They acknowledged the findings.

1. Med-techs and LN will complete training on Resident Rights and refusal of medication to ensure all staff unsterstand the proper protocol for handling medication refusals. Resident 4 and 5 were fully audited. Both providers are aware of past refusals now, and have expressed how often they would like to be notified moving forward. 2. The LN nurse will conduct a audit of all refused medications, and providers will be notified of any medication that may need removed to PRN fot D/C 3. The RCC will contuct daily audits of medication refusals and notify clincal team and discuss during stand-up 4. The Executive Director will monitor the process weekly for the first 60 days and there for once a week to ensure full compliance.

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 (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 MARs were accurate and included resident-specific parameters and staff instruction for 2 of 6 sampled residents (#s 1 and 2) whose medications were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 11/2023 with diagnoses including Type 2 diabetes mellitus and psychotic disturbance. The resident's MAR, dated 04/01/25 through 04/28/25, and physician's orders were reviewed. The resident had the following PRN bowel medications ordered for constipation: * Polyethylene glycol powder 17 gm dissolve in 4-8 oz fluid everyday PRN; and * Senna 8.6 mg, two tablets PRN. The MAR lacked instructions to unlicensed staff for which PRN medication to administer first. The need to ensure the MAR contained resident-specific parameters and instructions for PRN medications was discussed with Staff 1 (Regional Director of Operations) and Staff 2 (Regional Nurse Consultant) on 05/01/25 at 11:25 am. They acknowledged the findings. ?2. Resident 1 was admitted to the facility in 04/2025 with diagnoses including dysphagia and left hemiplegia following cerebral infarction (stroke) and vascular dementia. The resident’s MAR, dated 04/07/25 through 04/28/25, and physician’s orders were reviewed. The following was identified: a. The resident had two PRN medications for pain which did not include parameters for order of administration: * Oxycodone 10 mg; and * Acetaminophen 325 mg. b. The resident had two PRN medications for constipation which did not include parameters for order of administration: * Bisacodyl 10 mg; and * Milk of Magnesia 400mg/5ml. c. The resident had two PRN medications for stomach upset which did not include parameters for order of administration: * Dicyclomine 20 mg tablet; and * Milk of Magnesia 400 mg/5ml. The need to ensure PRN medications included resident-specific parameters and instructions for administration was reviewed with Staff 1 (Regional Director of Operations) and Staff 2 (Regional Nurse Consultant) on 05/01/25 at 10:20 am. They acknowledged the findings.

1. The facility LN will review all medication orders for reidents to ensure there are no duplicate orders and that all necessary parameters are in place. Resident 1 and 2 were fully audited. Duplicate orders were removed and parameters for all medications that need parameters are in place. 2. Med-techs and LN will complete relias training on medication admininstation to ensure proper understanding on parameters and medication direction. 3. Bi-weekly audits will be completed by the RCC to ensure all parameters are in place for medication. 4. The RN will review the parameter audits with the RCC on a weekly basis to ensure compliance and adress any discrepancies or issues. 5. The Executive Director will complete audits of the medication parameters and review results with the clincal team on a weekly basis to enure on-going compliances.

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 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: On the ABST [Acuity Based Staffing Tool] Facility Entrance Questionnaire, Staff 1 (Regional Director of Operations) identified there were 20 residents who required the assistance of two staff for transfers. The facility had a specific needs contract. A review of the facility’s ABST, the posted staffing plan, the staffing schedule for 04/21/25 through 04/27/25, the current resident roster, and the specific needs contract staffing requirements identified the following: * The facility’s posted staffing plan showed they scheduled nine caregivers and two MTs for day and swing shifts and five caregivers and one MT for NOC shift every day of the week. * Based on the staffing schedules provided, there were an insufficient number of staff approximately 38% of the time between 04/21/25 and 04/27/25. * The specific needs contract, based on the resident roster provided, revealed a total of 14 care staff (including MTs) were required for day and swing shifts and nine care staff (including MTs) were needed on the overnight shift. On 05/01/25 the need to have enough qualified direct care staff on each shift was discussed with Staff 1 and Staff 2 (Regional Nurse Consultant. They acknowledged the findings.

1. The facility will hire new caregivers and med-techs to meet the needs of the residents and ensure adequate staffing levels per the contract and ABST 2. Staffing will be addressed daily in stand-up meedtings, where open shifts will be discussed and the leadership team will ensure all shifts are covered and he leadership will ensure shifts are covered. 3. The staffing plan will be reviewed weekly with the ABST to ensure correct number of stafff are scheduled and working to meet the needs of the residents. 4. Executive Director and Staffing Coordinator will will monitor daily gaps and needs for staffing and ensure proper trained staff are working to meet the needs of our residents.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by:

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on interview, observation, and record review, it was determined the facility’s Acuity-Based Staffing Tool (ABST) did not accurately capture care time and care elements that staff were providing to each resident as outlined in each individual service plan for 3 of 6 sampled residents (#s 2, 4, and 5) and failed to develop an accurate staffing plan for each shift that met the scheduled and unscheduled needs of all residents. Findings include, but are not limited to: A review of ABST documentation, the posted staffing plan, the staffing schedule for 04/21/25 through 04/27/25, and the specific needs contract staffing requirements were reviewed. The following was identified: * The minutes recorded on the ABST did not match services provided by staff in multiple areas for Residents 2, 4, and 5. * The posted staffing plan and the staff schedule did not meet the staffing needs required by the specific needs contract. * There were not enough direct care staff on each shift to meet the scheduled and unscheduled needs of all residents. The need for the ABST to accurately capture care time and care elements that staff were providing to each resident and to develop an accurate staffing plan to meet the specific needs contract staffing requirements and the scheduled and unscheduled needs of all residents was discussed with Staff 1 (Regional Director of Operations) and Staff 2 (Regional Nurse Consultant) on 04/30/25 and 05/01/25. They acknowledged the findings and provided a plan for adding additional staff to each shift, as well as a staffing schedule for 05/01/25 through 05/15/25.

1. The SSD staffing coordinator will complete in-person training for the ABST 2. Staff levels will be reviewed daily levels during stand-up meetings to ensure approproaite amount of staff are scheduled for the week. 3. The staffing plan will be reviewed weekly by the Executive Director, SSD, and Staffing Coordinator and enure it matches the needs of the Contract and ABST 4. A complete audit of each resident will be conducted to ensure the ABST staffling plan aligns with the actual needs of the resident. This audit will be completed by the Executive Director.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. 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 their acuity-based staffing tool (ABST) evaluation was completed prior to a resident moving into the facility (Resident 1), failed to update the ABST when there were significant changes of condition (Residents 1 and 4), and failed to update the ABST at least quarterly for nine unsampled residents. Findings include, but are not limited to: ABST data was reviewed during the survey, from 04/28/25 through 05/01/25. The following was identified: 1. Resident 1 was admitted to the facility on 04/07/25, and his/her ABST was not entered until 04/17/25. The resident’s ABST was not updated with his/her significant change of condition which occurred on 04/22/25. 2. Resident 4 experienced a significant change of condition on 03/24/25 and his/her ABST data was not updated. 3. ABST data for nine unsampled residents had not been updated within the last 90 days. The requirements for completing and updating the ABST were discussed with Staff 1 (Regional Director of Operations) and Staff 2 (Regional Nurse Consultant) on 05/01/25. They acknowledged the findings.

1. The facility will place rock in the drop off area's by the dining room to the parking lot. 2. ED and Maintenance Director will completely weekly facility walks to ensure safety and complaiance.

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 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. Findings include, but are not limited to: The building was toured on 04/28/25 and 04/29/25. Observations and interviews with staff confirmed the doors by which residents could exit the facility did not have a working alarm or other acceptable system to alert staff when residents left the building. On 05/01/25, the need to ensure exit doors were equipped with an alarming device or other acceptable system was discussed with Staff 1 (Regional Director of Operations). She acknowledged the findings.

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 courtyard surfaces and surrounding pathways were maintained in good repair. Findings include, but are not limited to: Observations of facility pathways and patio areas on 04/28/25 and 04/29/25 identified the following: * Multiple drop-offs of two to three-and-a-half inches were noted along pathways leading out from the dining room exit doors connecting the parking lot to Bridge Street. The need to ensure pathways around the facility were in good repair were shown to and discussed with Staff 1 (Regional Director of Operations) and Staff 4 (Maintenance Director) on 04/30/25 at 1:35 pm. They acknowledged the findings.

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

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. Findings include, but are not limited to: Observations of the facility between 04/28/25 and 04/30/25 showed the following areas in need of cleaning or repair: a. Interior of the building: * First floor common area bathroom was found to have chipped and rough counter tops edges, and chipped and/or missing paint; * Dining room was found to have burned out light bulbs in multiple chandeliers and scuffs and gouges on the cabinets by the kitchen door and coffee buffet unit; * Handrail by Room 107 was loose; * Second floor laundry room had a corner guard missing, with exposed metal and peeling paint, and a section of the interior door frame was missing; * Third floor laundry room had a cracked light fixture, a corner protector was missing with an exposed rough surface, wall behind a washing machine had gaps around pipes that were not sealed, and linoleum was peeling up and/or a section was removed exposing rough surfaces and posed a tripping hazard; * Scuffs and gouges on multiple doors including, but not limited to, Rooms 114, 301, 305, and 310; * Left side of Room 305’s door frame was missing and Room 311 had a large dent noted on a door protector with exposed edges; and * During multiple interviews with staff and residents, it was reported the dining room floods by the exit door nearest the kitchen, requiring staff to use towels to soak up the water. During an interview with Staff 1 (Regional Director of Operations) and Staff 4 (Maintenance Director) on 04/30/25, they acknowledged water enters the dining room in through the exit door nearest the kitchen when there were heavy “sideways” rain. b. Exterior of the building: * Smoking tent had multiple cushions with dirt, debris, and black matter, and there was a large tear in the gazebo screen; * White railings were rough and peeling with rust-colored stains, and an exterior light fixture cover was missing by the exit door nearest Bridge Street; * Rust-colored stains were observed on the outside siding near the kitchen and the end section of the gutter directly above the stained siding was black and had holes in it; and * The base of the outside frame of two exit doors from the dining room was missing, with exposed jagged edges. The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Regional Director of Operations) and Staff 4 (Maintenance Director) on 04/30/25 at 1:35 pm. They acknowledged the findings.

1.The facility will replace the bathroom countertops to ensure functionality and appearance. 2. Facility will replace the dining room light, Coffee Bar. 3. Routine painting will be completed weekly for high traffic area's including resident doors and counter by the kitchen. 4.All hand rails will be checked weekly to ensure they are properly tightened and not loose on the wall for safety. 5. The paint in the secon-floor laundry room will be completed and corner gaurds replaced. 6. The third floor laundry room will have the floors, lighting fixtures, corner gaudrds will be replaced. All open area's behind the washers and dryers will be sealed. 7. Smoking area cushions will be replaced and the screeen will be removed from the gazebo Housekeeping and maintance will montior daily for trash debries. 8 The metal railing behind the facility will be sanded down and repained. 9. All broken outdoor lighting fixtures will be replaced. 10. The gutters outside the dining room will be repaied and rust spots will be cleaned or removed and replaced if unable to clean 11. The sealing by the door in the dining room will be replaced to prevent water from coming into the dining during heavy rain.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by:

OAR 411-054-0300 (11-13) Call System (11) CALL SYSTEM. An ALF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided at each resident bathroom, central bathing rooms, and public-use restrooms.(b) EXIT DOOR ALARMS. Exit door alarms or other acceptable systems must be provided for security purposes and to alert staff when residents exit the ALF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES.(a) RESIDENT PHONES. Each unit must have at least one telephone jack to allow for individual phone service.(b) PUBLIC TELEPHONE. There must be an accessible local access public telephone in a private area that allows a resident or another individual to conduct a private conversation.(13) TELEVISION ANTENNA OR CABLE SYSTEM. An ALF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. Findings include, but are not limited to: The building was toured on 04/28/25 and 04/29/25. Observations and interviews with staff confirmed the doors by which residents could exit the facility did not have a working alarm or other acceptable system to alert staff when residents left the building. On 05/01/25, the need to ensure exit doors were equipped with an alarming device or other acceptable system was discussed with Staff 1 (Regional Director of Operations). She acknowledged the findings.

1. The facility will ensure that the door alarms are properly installed and functioning 2. weekly monitoring by the exectuive Director and Maintenace Director will be completed and any concerns will be adressed. 3. Facility will integrate door alarms into the call light system for better monitoring and response. 4. The Executive Director, PIC during off hours, and maintenance will monitor this moving forward.

OAR 411-054-0300 (11-13) Call System (11) CALL SYSTEM. An ALF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided at each resident bathroom, central bathing rooms, and public-use restrooms.(b) EXIT DOOR ALARMS. Exit door alarms or other acceptable systems must be provided for security purposes and to alert staff when residents exit the ALF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES.(a) RESIDENT PHONES. Each unit must have at least one telephone jack to allow for individual phone service.(b) PUBLIC TELEPHONE. There must be an accessible local access public telephone in a private area that allows a resident or another individual to conduct a private conversation.(13) TELEVISION ANTENNA OR CABLE SYSTEM. An ALF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by: