Print Inspection: RL004704

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents’ current needs and provided clear direction regarding the delivery of services for 4 of 4 residents whose service plans were reviewed (#s 2, 3, and 5). Findings include but are not limited to: 1. Resident 3 was admitted to the facility in 01/2023 with diagnoses including stage III kidney failure and bladder cancer. Resident 3's charting notes from 03/03/25 through 06/03/25, service plan, and alert charting records were reviewed, and observations were made during the survey. Resident 3’s service plan, dated 04/07/25, was not current or lacked direction for staff in the following areas: * Multiple handwritten updates with no date or signature; * Use of a routine psychoactive medication for sleep; and * Presence and treatment of “sore on left inner buttock.” In an interview on 06/03/25 at 2:00 pm, Staff 3 (Resident Care Nurse / RN) acknowledged the service plan was not current or complete. The need to ensure the service plan was updated with current care needs was discussed with Staff 1 (Administrator), Staff 5 (RCC), and Staff 2 (Office Manager) on 06/05/25 at 2 pm. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 11/2015 with diagnoses including congestive heart failure and depression. Observations of the resident, interviews with the resident and staff, and review of the resident's most recent service plan, dated 03/21/25, and the “working” service plan showed the service plan did not provide clear direction to staff and/or was not reflective of the resident's needs in the following areas: * Safety checks, including frequency; * Staff instructions regarding how to monitor the oxygen was “appropriate”; and * Non-drug interventions not needing to be attempted prior to administering psychoactive medications for agitation. The need to ensure service plans were reflective of resident needs and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (Office Manager) on 06/05/25 at 2:30 pm. They acknowledged the findings. 3. Resident 2 was admitted to the facility in 04/2015 with diagnoses including cerebrovascular disease and anxiety. Observations of the resident, interviews with the resident and staff, and review of the resident's most recent service plan, dated 05/27/25, and the “working” service plan showed the service plan did not provide clear direction to staff and/or was not reflective of the resident's needs in the following areas: * Where the resident preferred to eat meals and at what time; * Diagnoses including congestive heart failure diagnosis, including what to look for; * No longer receiving hospice services, who to call for medication questions or emergent services, and who provided fingernail/toenail services; * Bathing services, including who provided and preferences for sponge bath versus showering; * Safety checks, including frequency; and * Providing dressing assistance when resistant to changing clothes. The need to ensure service plans were reflective of resident needs and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (Office Manager) on 06/05/25 at 2:30 pm. They acknowledged the findings. 4. Resident 5 was admitted to the facility in 09/2024. Interviews with an unsampled resident and staff were conducted, and the current service plan, dated 04/29/25, and a smoking evaluation and risk assessment, dated 04/14/25, were reviewed. In an interview with an unsampled resident on 06/02/25, Resident 5 was identified to smoke on his/her patio and in the apartment. The smoking assessment identified the resident had a history of smoking indoors or in non-smoking areas. The risk assessment included that the resident agreed to smoke in the designated smoking areas or risk a “move out notice.” The service plan lacked clear instructions to staff on what to do if they witnessed the resident smoking outside of designated smoking areas. Prior to exit, an update to the service plan was provided that included instructions to staff regarding what actions to take if the resident was found smoking outside of designated areas. In an interview with Staff 2 (Office Manager) on 06/05/25, she confirmed Resident 5 had been known to smoke on his/her patio but this had been addressed, and the resident had agreed not to continue. She acknowledged it had “been a few months at least” since the Resident was found to smoke outside of the designated areas. No observations were made during survey of Resident 5 smoking on his/her patio or in his/her apartment. The need to ensure service plans provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (Office Manager) on 06/05/25 at 2 :30 pm. They acknowledged the findings.

1. Service Plans noted to be deficient to be updated to reflect current care needs and other deficiencies. 2. Re-train staff on dating and initialing handwritten entires and ensuring service plans are reflective of care and give clear diretion to the staff. 3. Service plans reviewed by care team and updated quarterly and at change of condition. 4. Administrator, RCC, Nurse

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 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure changes of condition were evaluated to determine the action or intervention needed and monitored until resolution for 3 of 3 residents reviewed for change of condition (#s 1, 2, and 3). Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 01/2023 with diagnoses including stage III kidney failure and bladder cancer. Resident 3's charting notes from 03/03/25 through 06/03/25, service plan, and alert charting records were reviewed, and observations were made during the survey. Resident 3 experienced the following changes of condition: * 04/01/25 progress noted documented the discovery of blood in Resident 3’s catheter bag, along with redness and a small blister near the catheter insertion site; * 04/02/25 alert charting notes documented skin with bright red color, small red bumps, and a “bruise adjacent to urethra”; and * 04/07/25 service plan documented “a sore on left inner buttock.” In an interview on 06/03/25 at 2:00 pm, Staff 3 (Resident Care Nurse / RN) acknowledged there was no documented evidence of evaluation of the wounds or monitoring until resolution. The need to ensure wounds were evaluated to determine what intervention was needed and were monitored until resolution was discussed with Staff 1 (Administrator), Staff 5 (RCC), and Staff 2 (Office Manager) on 06/05/25 at 2:00 pm. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 11/2015 with diagnoses including congestive heart failure and depression. The resident's 03/21/25 service plan, “working” service plan, alert charting, 03/01/25 through 05/31/25 progress notes, and outside provider notes were reviewed. a. The following short-term changes of condition lacked monitoring of progress noted weekly through resolution: * 03/01/25 – Start of senna (for constipation); * 03/08/25 – Missed trazodone (for sleep); * 04/03/25 – Diarrhea; * 04/06/25 - Missed ferrous sulfate (supplement); * 04/29/25 – New medication loperamide (for diarrhea); * 05/13/25 – Forgetting to put oxygen back on after ADLs; and * 05/20/25 – Start acetaminophen PRN for pain. b. An outside provider note from the hospice RN, dated 04/28/25, noted “an old blister that is healing on R (right) heel.” There was no documented evidence the heel was evaluated to determine actions/interventions and monitoring of progress noted weekly through resolution. In an interview on 06/04/25, Staff 3 (Resident Care Nurse/RN) acknowledged she did not have a system for monitoring skin conditions, and she had not evaluated the resident’s heel. Survey requested the heel be evaluated prior to exit and documentation was provided on 06/05/25 that the heel blister had healed. The need to ensure changes of condition had actions/interventions determined and monitored through resolution was discussed with Staff 1 (Administrator) and Staff 2 (Office Manager) on 06/05/25 at 2:30 pm. They acknowledged the findings. 3. Resident 2 was admitted to the facility in 04/2015 with diagnoses including cerebrovascular disease and anxiety. The resident's 05/27/25 service plan, “working” service plan, alert charting, and progress notes, dated 03/01/25 through 05/31/25, were reviewed. The following short-term changes of condition lacked monitoring of progress noted weekly through resolution: * 04/11/25 – Start liquid potassium (supplement); * 05/05/25 – Warfarin (blood thinner) dosage change; and * 05/08/25 – Erythromycin for eye infection. The need to ensure changes of condition were monitored through resolution was discussed with Staff 1 (Administrator) and Staff 2 (Office Manager) on 06/05/25 at 2:30 pm. They acknowledged the findings.

1. Residents short term changes of condition to be added to alert charting and monitored through resolution. 2. Retrain medaides, RCC/Nurse on current Policy and Procedure for Alert charting on short term changes of condition and requirement to progress note at least weekly through resolution. 3. Medaide to review daily. RCC/Nurse to review weekly. 4. Administrator, RCC/Nurse

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 observation, interview and record review, it was determined the facility failed to ensure a significant change of condition assessment was completed by the RN, which included findings, resident status, and interventions, for 1 of 1 sampled resident (# 1) who experienced a significant change of condition. Resident 1 was admitted to the facility in 11/2015 with diagnoses including congestive heart failure and depression. Progress notes dated 03/01/25 through 05/31/25 were reviewed, and identified Resident 1 was admitted to hospice services on 04/23/25. The hospice admission constituted a significant change of condition, for which an RN assessment was required. On 04/23/25 an RN assessment was completed but did not include resident’s status and interventions made as a result of the assessment. In an interview on 06/04/25, Staff 3 (Resident Care Nurse/RN) acknowledged the RN assessment lacked the required components following Resident 1’s admission to hospice services. The need to ensure RN assessments included findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (Administrator) and Staff 2 (Office Manager) on 06/05/25 at 2:30 pm. They acknowledged the findings.

1. Significant Change of Condition RN Assessment to be completed with missing information. 2. Retrain RN on requirements for significant changes of condition to ensure assessments are thorough and include resident status and interventions made. 3. With each significant change of condition. 4. Administrator, RN

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 411-054-0055 (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 1 of 1 sampled resident (#1) whose MARs and Controlled Substance Disposition logs were reviewed. Findings include, but are not limited to: Resident 1 was admitted to the facility in 11/2015 with diagnoses including congestive heart failure and depression. Observations of the resident, interviews with resident and staff, and record review were completed. The resident's signed physician orders, dated 04/23/25, included the following: * Hydrocodone/Acetaminophen 5 mg-325 mg, 2 tablets once daily at bedtime for pain; and * Hydrocodone/Acetaminophen 10 mg-325mg, 1 tablet every four hours as needed for pain, not to exceed four tablets in 24 hours. The resident's Controlled Substance Disposition logs and MARS, reviewed from 05/01/25 through 06/01/25, showed the following: * A dose was signed out in the disposition log on 05/10/25 at 12:51 with no indication of am or pm. The MAR reflected it was administered at 2:03 am. * A dose was signed out in the disposition log on 05/11/25, and the dose was not reflected in the MAR. * A dose was signed out in the disposition log on 05/11/25 at 4:27 pm but not reflected on the MAR. That same day, a dose was signed on the narcotics log at 11:30 pm and noted “popped in error not given” but was shown as administered at 11:30 pm. There was no documented evidence the pill not given was destroyed. In an interview on 06/04/25, Staff 3 (Resident Care Nurse/RN) indicated she was present when the medication was destroyed but acknowledged there was no documented evidence the tablet had been destroyed. Comparison of the medication in pill bottles and bubble packs to the disposition logs showed the amount of medication left was reflected accurately on the log. The need to ensure narcotic disposition logs accurately reflected the medications administered was discussed with Staff 1 (Administrator) and Staff 2 (Office Manager) on 06/05/25 at 2:30 pm. The staff acknowledged the findings.

1. Retraining of MAs on proper documentation on medication administration to MAR and Narcotic administration log. 2. MAR has been updated to reflect dosing as documented on narcotic adminsitration log. 3. Daily by Medication Aides and weekly by RCC. 4. Administrator, RCC, Nurse

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 medication orders were carried out as prescribed and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications the facility was responsible for administering for 2 of 3 sampled residents (#s 2 and 3) whose records were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 04/2015 with diagnoses including cerebrovascular disease and anxiety. The resident's 05/01/25 to 06/02/25 MARs and physician orders signed 04/11/25 were reviewed. The following was identified: a. Baclofen 10 mg, half a tablet three times a day and half a tablet PRN (for muscle spasms) was ordered. The order for routine baclofen was missing on the MAR and the PRN order was being administered two times daily as needed. b. Diltiazem 120 mg (for high blood pressure) twice daily was ordered. The MAR indicated it was administered 240 mg once daily. c. The following medications were noted on the MAR but the orders were missing: * Spiriva 2.5 mcg/ACT (for asthma) 2 puffs daily; * Trazodone 50 mg (for sleep) 1 tablet PRN; * Acetaminophen 325 mg (for pain) 2 tablets every four hours PRN; * Senna 8.6 mg (for constipation) 2 tablets two times a day PRN; and * Lidocaine 4% patch (for pain) daily up to 12 hours PRN. d. The following medications were ordered but were missing on the MAR and no discontinue orders were provided: * Culturelle 15B (probiotic) daily; * Acetaminophen 650 mg suppository every 6 hours PRN for pain; * Guaifenesin 600 tab every 12 hours PRN for congestion/cough; * Hyoscyamine 0.125mg every 6 hours PRN for excessive secretions or terminal congestion; * Iprat/Albuterol 0.5-2.5 mg/3 mL 1 puff via nebulizer every 6 hours PRN for chest congestion/wheezing; and * Bisacodyl 100 mg suppository daily PRN for constipation. e. Erythromycin 5 mg/gram ointment to be applied to affected eye(s) three times a day for seven days for an eye infection was ordered on 05/04/25. The medication was scheduled on the MAR to be administered at 8:30 am, 2:00 pm and 7:00 pm. On 05/09/25 the MAR indicated the medication was “suspended 09 May 2025 to 13 May 2025: Waiting on order”. The medication was shown as administered starting on 05/13/25 at 2:00 pm and the last dose was given on 05/15/25 at 7:00 pm. The medication was not administered for seven days as ordered. In an interview on 06/05/25, Staff 5 (RCC) acknowledged the orders were missing and/or not being followed as prescribed. She stated, “We’ll work on getting the medications updated.” No further information was provided. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed and available in the resident's facility record was reviewed with Staff 1 (Administrator) and Staff 2 (Office Manager) on 06/05/25 at 2:30 pm. The findings were acknowledged. 2. Resident 3 was admitted to the facility in 01/2023 with diagnoses including stage III kidney failure and bladder cancer. Resident 3's charting notes from 03/03/25 through 06/03/25, service plan, medication administration records, physician’s orders, and alert charting records were reviewed, and observations were made during the survey. The following was identified: A 05/09/25 incident investigation noted Resident 3 was given the following medications in error: * Acetaminophen 500mg (analgesic); * Amlodipine 5mg (blood pressure); * Aspirin 81mg (analgesic); * Cefuroxime 250 mg (antibiotic); * Eliquis 2.5 mg (blood thinner); * Glipizide 5 mg (blood sugar): * Isosorbide 30 mg (heart disease); * Jardiance 25 mg (blood sugar); * Omeprazole 20 mg (gastric reflux); * Pregabalin 75mg (anticonvulsant); * Senna-docusate 8.6 mg (constipation); and * Tamsulosin .4 mg (prostate health). The medication errors were reported to Staff 3 (Resident Care Nurse / RN), who contacted Resident 3’s physician for instructions and investigated the incident. Resident 3 was monitored for 72 hours, without experiencing a negative outcome. The need to ensure residents received only the medications they were prescribed and that medications were given as ordered was discussed with Staff 1 (Administrator), Staff 3, Staff 5 (RCC), and Staff 2 (Office Manager) on 06/05/25 at 2:00 pm. They acknowledged the findings.

1. The resident's medication administation record was corrected to reflect the current Physician's order. 2. Medication Aides have been counseled and will be retrained on the facility procedure for reviewing new orders to ensure transcription is correct. If an error has been found in the pharmacy's transcription, the Medication Aide is to contact the pharmacy immediately and then notify the RCC/Nurse. 3. Medication orders will be reviewed daily by Medication Aides and RCC/Nurse to ensure new orders are reflected on the Medication Administation Record. 4. Administrator, RCC, Nurse

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 411-054-0070 (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 06/02/25, Staff 1 (Administrator) completed the “ABST Entrance Questionnaire” and the following was identified: Review of the facility's posted staffing plan and ABST data from 05/26/25 through 06/01/25 indicated the following: * Day Shift: 6:00 am to 2:00 pm – 2 MAs and 2 CG’s; * Afternoon Shift : 2:00 pm to 10:00 pm – 2 MAs and 2 CG’s; * Overnight Shift: 10:00 pm to 6:00 am – 1 MA and 1 CG; and * Seven of seven days reviewed were not staffed to the posted staffing plan. Following the review of the facility ABST and posted staffing plan it was determined the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents. The need to have a sufficient number of staff to meet all scheduled and unscheduled needs of residents on day, swing and night shifts was discussed with Staff 1 and Staff 2 (Office Manager) on 06/05/25 at 3:15 pm. They acknowledged the findings. Refer to C362 and C363.

1. Community staffing plan to be updated per ABST to reflect accurate staffing based on resident needs to meet the scheduled and unscheduled needs. 2. RCC to be retrained on updating the ABST and the community staffing plan after each resident service plan change. 3. Quarterly, at change of condition and as needed 4. Administrator, RCC

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 and record review, the facility failed to accurately capture care time and care elements that staff were providing to each resident as outlined in each individual service plan for 3 of 3 sampled residents (#s 1, 2, and 3) whose individual ABST minutes were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 01/2023 with diagnoses including stage III kidney failure and bladder cancer. Resident 3's charting notes from 03/03/25 through 06/03/25, service plan, and alert charting records were reviewed, and observations were made during the survey. The resident's care time and care elements were found to not be reflective in the following areas: * Safety checks and fall prevention; * Responding to call lights; * Bowel and bladder management; and * Dressing and undressing. The need to ensure the facility ABST accurately captured care time and care elements that staff were providing was discussed with Staff 1 (Administrator) and Staff 2 (Office Manager) on 06/05/25 at 2:00 pm. The findings were acknowledged. 2. Resident 1 was admitted to the facility in 11/2015 with diagnoses including congestive heart failure and depression. The service plan, dated 03/21/25, “working” service plan, alert monitoring, and the resident's corresponding ABST individual minutes were reviewed. The resident was observed, and interviews were conducted with staff and the resident. The resident's care time and care elements were found to not be reflective in the following areas: * Safety checks and fall prevention; * Responding to call lights; * Time spent monitoring behavioral conditions or symptoms; * Bowel and bladder management; and * Dressing and undressing. The need to ensure the facility ABST accurately captured care time and care elements that staff were providing was discussed with Staff 1 (Administrator) and Staff 2 (Office Manager) on 06/05/25 at 2:30 pm. The findings were acknowledged. 3. Resident 2 was admitted to the facility in 04/2015 with diagnoses including cerebrovascular disease and anxiety. The service plan, dated 05/27/25, “working” service plan, alert monitoring, and the resident's corresponding ABST individual minutes were reviewed. The resident was observed, and interviews were conducted with staff and the resident. The resident's care time and care elements were found to not be reflective in the following areas: * Safety checks and fall prevention; * Responding to call lights; * Time spent monitoring behavioral conditions or symptoms; and * Bowel and bladder management. The need to ensure the facility ABST accurately captured care time and care elements that staff were providing was discussed with Staff 1 (Administrator) and Staff 2 (Office Manager) on 06/05/25 at 2:30 pm. The findings were acknowledged.

1. The ABST to be updated to accurately capture the care time. Resident service plans will be reviewed to ensure accurate care is accounted for and will then base staffing needs off of resident acuity. 2. Resident service plans will be reviewed to ensure accurate care is accounted for and will then base staffing needs off the resident acuity. 3. With each service plan update 4. Administrator, RCC

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 the acuity-based staffing tool (ABST) was completed and/or updated and reviewed before a resident moved in, whenever there was a significant change of condition, and/or no less than quarterly at the same time the resident’s service plan was updated for 3 of 4 sampled residents (#s 1, 2, and 4) and five unsampled residents whose ABST updates were reviewed. Findings include, but are not limited to: On 06/02/25 the facility provided the ABST Entrance Questionnaire and documentation requested. The following was identified: The facility used an approved proprietary ABST; however, there was no historic data including the date each resident was entered into the facility’s ABST. 1. There were five unsampled residents who had documented move-in dates prior to 06/02/25, however the ABST data was dated 06/02/25. Additionally, Resident 4 moved into the facility on 04/04/25 and the ABST was dated 04/30/25. On 06/04/25 at 10:05 am, Staff 1 (Administrator) and Staff 2 (Office Manager) stated all five residents were entered into the ABST the day survey entered the facility. They also confirmed Resident 4 was not entered into the ABST prior to moving in. The need to ensure residents were entered into the facility ABST before move-in was reviewed with Staff 1 and Staff 2 on 06/05/25 at 3:15 pm. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 11/2015 with diagnoses including congestive heart failure and depression. The service plan, dated 03/21/25, “working” service plan, alert monitoring, progress notes, dated 03/01/25 to 05/31/25, and the resident’s corresponding ABST evaluation were reviewed. It was noted Resident 1 experienced a significant change of condition on 04/23/25 for admission to hospice. However, the last ABST evaluation update for the resident was dated 03/27/25. The need to ensure the ABST was updated and reviewed following a significant change of condition was discussed with Staff 1 (Administrator) and Staff 2 (Office Manager) on 06/05/25 at 2:30 pm. The findings were acknowledged. 3. Resident 2 was admitted to the facility in 04/2015 with diagnoses including cerebrovascular disease and anxiety. The service plan, dated 05/27/25, “working” service plan, alert monitoring, progress notes dated 03/01/25 to 05/31/25, and the resident’s corresponding ABST evaluation were reviewed. The last ABST update for the resident was 03/05/25, and data was not updated quarterly at the same time the resident’s service plan was updated. The need to ensure the ABST was updated and reviewed quarterly when the service plan was updated was discussed with Staff 1 (Administrator) and Staff 2 (Office Manager) on 06/05/25 at 2:30 pm. The findings were acknowledged.

The residents whose ABST had not been updated to refect changes in care needs will be updated. 2. RCC/Nurse to be retrained on ABST process of completing it prior to move in and with each care change. 3. At move in and with each residents service plan update. 4. Administrator, RCC, Nurse

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

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to instruct residents within 24-hours of admission and re-instruct residents, at least annually, on the facility’s fire and life safety procedures. Findings include, but are not limited to: On 06/02/25, the past six months of fire and life safety records were requested for review. On 06/03/25 at 10:06 am, Staff 2 (Office Manager) stated documentation of fire and life safety instruction within 24-hours would be in resident charts; however, documentation provided did not indicate residents were instructed within 24-hours of move in. Staff 2 also stated there was no documentation residents were instructed at least annually. She indicated, however, there was a system for retraining residents annually in fire and life safety and it would be reimplemented. On 06/03/25 at 10:16 am, Staff 1 (Administrator) and Staff 2 confirmed there was no documentation residents were instructed in fire and life safety within 24-hours of admission or at least annually. The need to ensure residents were instructed within 24-hours of admission and re-instructed on the facility’s fire and life safety procedures, at least annually, was reviewed with Staff 1 and Staff 2 on 06/05/25 at 3:15 pm. They acknowledged the findings.

1. Residents to be trained and documented on fire and life safety. 2. Maintenance supervisor to be retrained on need to train residents within 24hr of move in and annually. 3. With each move in and annually. 4. Administrator, Maintenance supervisor, Office Manager

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

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory care communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the grounds were orderly and free of litter and refuse. Findings include, but are not limited to: The grounds of the facility were toured on 06/02/25. The following was identified: * The dumpster area had black debris on the ground, with piles of leaves, discarded gloves, plastic cups and bags, and miscellaneous trash. The building's exterior was toured on 06/05/25 at 10:07 am with Staff 4 (Maintenance Supervisor), and at 12:00 pm with Staff 1 (Administrator). They acknowledged the findings and the need to ensure the grounds were orderly and free of litter and refuse.

1. The grounds and dumpster area to be cleaned. 2. Maintenance supervisor to walk grounds daily and clean up refuse. 3. Daily by Maintenance supervisor and weekly by Administrator. 4. Administrator, Maintenance supervisor

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 06/02/25 and 06/05/25 showed the following areas in need of cleaning or repair: * Multiple doors were observed to have chipped paint and/or black scuff marks including, but not limited to, Unit #s 2, 3, 9, 17, 25, and 27, B, and the kitchen door leading into the hallway; * Carpet throughout the building was bunched up in multiple areas and posed a tripping hazard. Multiple interviews with staff reported residents and staff have had “several near or missed trips” and chairs in the dining room do not slide easily because of the “loose” carpet; * Walls throughout the facility had holes, chips, scrapes, and dings, including wall and post corners, and/or had been patched but not painted to match the current wall color. Additionally, the vaulted ceiling near Units E and H had multiple areas with black dots; * The handrail was loose by Units I-J; * The exterior of the building had cobwebs, dirt, lint, and debris in multiple areas including, but not limited to, resident patios, breezeway near activity room, and outside patio by the dining room. Multiple patio chairs had dirt and debris; * The resident-use laundry room had lint and debris behind the washing machine and dryers, small holes on the wall in multiple locations, and the spa handle for the drain was broken; * The walls in the staff laundry room had multiple holes, stains, and rough textures, a piece of baseboard was missing behind the door, and a lightbulb was burned out; * The common use bathroom by the activity area had chipped linoleum in multiple areas; and * The bathroom sink in Unit I was loose and separating from the wall. The building's interior and exterior were toured on 06/05/25 at 10:07 am with Staff 4 (Maintenance Supervisor) and at 12:00 pm with Staff 1 (Administrator). They acknowledged the findings and the need to ensure the environment was maintained clean and in good repair.

1. The areas of conerns on the interior and exterior to be cleaned, painted, repaired, etc. 2. Maintenance supervisor to be retrained on CPM policies and procedures to follow routine building maitenance tasks and logs. 3. Monthly building walks and audits of maintenance logs and task sheets. 4. Administrator, Maintenance supervisor

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 alert staff when residents exited the building. Findings include, but are not limited to: On 06/04/25 the following was revealed: At 9:30 am, Staff 14 (Dietary Manager) was observed using a tool on the exit doors in the dining room and stated staff had pagers that were notified when the exit doors opened and closed. At 9:52 am, the facility exit doors were opened and closed with Staff 7 (MA). When the exit doors were opened, the pager Staff 7 had was not alerted. At 10:04 am, Staff 4 (Maintenance Supervisor) confirmed the pagers were only notified from approximately 8:00 pm to 7:00 am. The need to ensure exit doors were equipped with an alarming device or other acceptable system that alerted staff when residents exited the building was reviewed with Staff 1 (Administrator) and Staff 2 (Office Manager) on 06/05/25 at 3:15 pm. They acknowledged the findings.

1. Exit doors are equipped with alarming device. 2. Maintenance Supervisor will audit system to ensure all exit doors are alerting pagers with notification to alert staff. 3. System will be audited weekly 4. Administrator. Maintenance supervisor

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:

OAR411-004-0020(2)(i) Individual freedom & Support: Activities (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (i) Each individual has the freedom and support to control his or her own schedule and activities. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure 2 of 5 sampled residents (#s 2 and 4) were supported in their right to control their own activities and schedules. 1. Resident 2 was admitted to the facility in 04/2015 with diagnoses including cerebrovascular disease and anxiety. Review of the resident’s progress notes, dated 03/01/25 through 05/31/25, and service plan, dated 05/27/25, was completed, and interviews with the resident and staff were conducted. The resident’s service plan indicated s/he required staff assistance with the use of a wheelchair for mobility, that s/he would request escorts to and from the dining room at mealtimes and would self-propel his/her wheelchair part of the time and need staff assistance part of the time. Observations between 06/03/25 and 06/05/25 revealed the resident self-propelled his/her wheelchair to lunch, started self-propelling his/her wheelchair back to his/her unit after lunch, but then used his/her call pendant to request assistance with toileting at the same time. In an interview on 06/03/25, Resident 2 indicated, "They [facility] serve meals at 8:00, 12:00, and 5:00. I make sure I'm there.” S/he did not feel they had control of when they could eat in the dining room. When the resident was asked if, for example, s/he could eat dinner at 5:30 pm instead, Resident 2 responded, "No, I either would not be fed or I would have to eat in my room." Resident 2 also indicated “there is a rule that I have to be in the dining room for 30 minutes before I can go back to my room.” S/he indicated s/he left the footrests off of his/her wheelchair so s/he could use their feet to self-propel back to his/her apartment. In an interview on 06/04/25 at 1:36 pm, Staff 7 (Medication Aide) reported “The rule is [s/he] has to wait half an hour once in the dining room before we can help [Resident 2] because we are getting meal trays done and don’t always have the staff available to help [him/her]. [S/he] wants to go back 15-20 minutes after a meal starts and so we tell [him/her] to please wait. Our priority is to get the meals out while they are hot.” In an interview on 06/05/25 at 2:30 pm, Staff 2 (Office Manager) clarified, “The rule came about because the resident would come to a meal in the dining room and spend five minutes at the table, would not eat, and then ask staff to take [him/her] back [to the apartment].” She added staff encouraged Resident 2 to eat and they created “a rule [Resident 2] needed to stay in the dining room for 30 minutes before staff would provide assistance back to his/her apartment. [S/he] was able to wheel [himself/herself] but [s/he] would see others getting pushed back to their rooms and ask, ‘Why can’t I get that?” The need to ensure residents had the freedom and support to control their own schedule was discussed with Staff 1 (Administrator) and Staff 2 (Office Manager) on 06/05/25 at 2:30 pm. They acknowledged the findings. Refer to C 260. 2. Resident 4 was admitted to the facility in 04/2025 with diagnoses including basal cell carcinoma. The resident’s current service plan, dated 03/21/25, was reviewed, and interviews with Resident 4 and staff were conducted. The following was identified: On 06/03/25 at 11:37 am, Resident 4 stated “meal service was at 8:00 am, 12:00 pm, and 5:00 pm.” The resident continued to say s/he did not eat breakfast in the dining room often because s/he liked to “sleep until 9:00 or 9:30 am” and confirmed s/he would eat breakfast if it was served later. The resident was not offered breakfast at a later time based on his/her preferred schedule. The need to ensure residents had the freedom and support to control their own schedule was discussed with Staff 1 (Administrator) and Staff 2 (Office Manager) on 06/05/25 at 3:15 pm. They acknowledged the findings.

1. Resident service plans to be updated with resident preference of meal times. 2. Staff to be re-educated on resident rights to freedom and support and control of their own schedule. 3. With each service plan update and as needed. 4. Adminstrator, RCC, Nurse

OAR411-004-0020(2)(i) Individual freedom & Support: Activities (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (i) Each individual has the freedom and support to control his or her own schedule and activities. This Rule is not met as evidenced by: