Print Inspection: RL005150

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an allergic reaction and an injury of unknown cause were promptly investigated, reviewed by the Administrator, and reported to the local SPD office or the local AAA office when abuse and/or neglect could not reasonably be ruled out, for 2 of 2 sampled residents (#s 1 and 4) who had incidents that were reviewed. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 12/2023 with diagnoses including hypertension and schizophrenia. The resident's record, including the 05/22/25 service plan, 06/01/25 through 06/23/25 MAR, and 03/23/25 through 06/23/25 progress notes were reviewed, and staff and resident were interviewed. The following was identified: * 05/03/25 – “Resident said [s/he] was having an allergic reaction to garlic, [s/he] used her epi pen and paramedics were called. [S/he] decided to go to the hospital to make sure [s/he] was ok." During an interview on 06/24/25 at 1:15 pm, Resident 4 stated the allergic reaction was due to garlic in ranch dressing served by the facility. S/he self- administered an Epi-Pen, pulled the cord to alert staff, and was sent to the emergency room. Resident 4’s service plan and MAR indicated the resident had some food allergies, which included garlic. During an interview on 06/24/25 at 2:40 pm, Staff 6 (Dietary Services Manager) stated the kitchen staff had laminated cards for each resident who had allergies. She confirmed Resident 4 was listed as having allergies to garlic. There was no documented evidence the 05/03/25 incident was investigated or reviewed by the Administrator. The facility was instructed to report the incident to the local SPD office, and confirmation of the report was received on 06/25/25 at 9:19 am when surveyor observed Staff 1 (ED) calling in the report to the local SPD office. The need for prompt investigations of incidents to immediately rule out abuse and/or neglect, and to self-report incidents to the local SPD office if abuse and/or neglect cannot reasonably be ruled out, was discussed with Staff 1, Staff 2 (Expressions Director), and Witness 1 (RN Consultant) on 06/26/25 at 10:20 am. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 12/2023 with diagnoses including left hemiplegia (weakness) and type 2 diabetes. The resident's service plan, dated 5/12/25, and incident reports and progress notes dated 03/23/25 through 06/23/25 were reviewed, and staff were interviewed. The following was identified: On 06/19/25, an incident report stated that a staff member observed a skin tear on the resident’s left forearm. The report stated the resident “does not know what happened.” There was no documentation of an investigation which concluded the injury was not a result of abuse. On 06/25/25 Staff 1 (ED) confirmed there was no additional documentation available and that the injury of unknown cause had not been reported to the local SPD office. All incidents of abuse or suspected abuse were reported to the local SPD office at request of surveyors by 06/26/25. The need to ensure injuries of unknown cause were reported to the local SPD office as suspected abuse, unless an immediate investigation concluded and documented that the injury was not the result of abuse, was reviewed on 06/26/25 at 1:30 pm with Staff 1 and Staff 2 (Expressions Director). They acknowledged the findings.

Items referenced to be out of compliance with OAR 411-054-0028 (2) (C 231) will be addressed, corrected and facility will be in compliance by 8/25/25 by completing the following: • Resident #1 & #4 incidents cited were investigated and reported as applicable • Licensed Nurse or Designee reviewed last 30 days of incidents on current residents for proper investigation and reporting, addressing concerns identified • Designee re-educated ED, HSD and RCC on incident investigation and reporting requirements • Incidents will be reviewed via SMART meeting for investigation and reporting compliance weekly x 3 weeks then monthly x 2 months • ED/HSD/Licensed Nurse is responsible Items referenced to be out of compliance with OAR 411-054-0034 (c) (C 252) will be addressed, corrected and facility will be in compliance by 8/25/25 by completing the following: Resident #2 no longer resides in the community • Licensed Nurse or Designee reviewed move-in evaluations for residents who have moved-in over the last 60 days, addressing concerns identified • Designee re-educated ED and HSD on the Move In Evaluation required elements • Licensed Nurse or Designee will review move in evaluations for new residents for compliance weekly x 3 weeks then monthly x 2 months •The Administrator or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until compliance has been achieved as determined by the committee. • HSD/ED/Licensed Nurse is responsible

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 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the initial move-in evaluation addressed all required elements, including documentation of who was involved in the evaluation process, for 1 of 1 sampled resident (#2) who was recently admitted to the facility. Findings include, but are not limited to: Resident 2 was admitted to the facility in 06/2025 with diagnoses including Barrett’s esophagus with dysplasia (a precancerous condition of the esophagus) and protein calorie malnutrition. The following was identified: a. The evaluation did not indicate who completed the evaluation. b. The following required elements were either left blank or were not included on the evaluation form: * Pronouns; * Gender identity; * Customary routines, such as those related to sleeping, eating, and bathing; * Interests, hobbies, and social and leisure activities; * Spiritual and cultural preferences and traditions; * Physical health status, including list of current diagnoses, list of medications and PRN use, visits to health practitioner (s), emergency room, hospital, or nursing facility in the past year, and vital signs if indicated by diagnoses, health problems, or medications; * Mental health issues, including presence of depression, thought disorders, or behavioral or mood problems, history of treatment and effective non-drug interventions; * Cognition, including memory, orientation, confusion; and decision-making abilities; * Personality, including how the person copes with change or challenging situations; * Communication and sensory abilities, including hearing, vision, speech, use of assistive devices, and ability to understand and be understood; * Activities of daily living, including toileting, bowel and bladder management, dressing, grooming, bathing and personal hygiene, mobility - ambulation, transfers and assistive devices, and eating, dental status and assistive devices; * Independent activities of daily living, including ability to manage medications, housework and laundry and transportation; * Pain, pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort; * Skin condition; * Nutrition habits, fluid preferences, and weight if indicated; * List of treatments, type, frequency, and level of assistance needed; * Indicators of nursing needs, including potential for delegated nursing tasks; * Review of risk indicators, including fall risk or history, emergency evacuation ability, complex medication regimen, history of dehydration or unexplained weight loss or gain, recent losses, unsuccessful prior placements, elopement risk or history, smoking, ability to smoke safely, alcohol and drug use, not prescribed by a physician must be evaluated and addressed in the resident’s service plan; and * Environmental factors that impact the resident's behavior including, but not limited to, noise, lighting and room temperature. The need to ensure the resident's initial move-in evaluation was signed and addressed all required elements was reviewed with Staff 1 (ED), Staff 2 (Expressions Director) and Witness 1 (RN Consultant) on 06/26/25. They acknowledged the findings.

Items referenced to be out of compliance with OAR (C 252) will be addressed, corrected and facility will be in compliance by 8/25/25 by completing the following: • Resident #2 no longer resides at Community • Licensed Nurse or Designee reviewed move-in evaluations for residents who have moved-in over the last 60 days, addressing concerns identified •Designee re-educated ED, HSD, RCC and Med Techs on the requirement that service plans are readily available to staff, were reflective and provide clear direction to staff. Training also included how staff communicates updates or changed needed to service plan. • Designee re-educated ED and HSD on the Move In Evaluation required elements •Licensed Nurse or Designee will review move in evaluations for new residents for compliance weekly x 3 weeks then monthly x 2 months •The Administrator or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until compliance has been achieved as determined by the committee. •The Administrator or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until compliance has been achieved as determined by the committee. •HSD/ED/Licensed Nurse is responsible

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

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and preferences, were readily available to staff, provided clear direction to staff regarding the delivery of services and included a written description of who shall provide the services and what, when, how, and how often the services shall be provided for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 06/2025 with diagnoses including Barrett’s esophagus with dysplasia (a precancerous condition of the esophagus) and protein calorie malnutrition. The resident’s record, including progress notes dated 06/09/25 through 06/20/25 were reviewed. Observations were made, and the resident and staff were interviewed. The following was identified: a. On 06/23/25, the survey team entered the facility to conduct a re-licensure survey. There was no documented evidence Resident 2’s service plan was available for staff in the service plan binder. Resident 2’s service plan was requested. The facility provided a printed copy of Resident 2’s service plan on 06/24/25. b. A review of resident 2’s service plan dated 06/09/25 was completed. The service plan was not reflective of the resident’s needs and did not provide clear direction to staff in the following areas: * Hospice services and schedule; * Aspiration precautions; * Pureed diet and thin liquids to drink; * Use of dentures and oral care; * Catheter care; * Incontinence care provided in hospital bed; * Level of assistance needed for ADLs, including transfers, bed mobility, and ambulation; * Use of wheelchair; * Skin condition including wound status and treatment; * Use of a hospital bed with an air mattress; * Use of side rails, including safety precautions; * Ability to use call system; * Pain, pharmaceutical and non-pharmaceutical interventions; and * Emergency evacuation ability. On 06/26/25, the need to ensure service plans were readily available to staff, were reflective and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (Expressions Director) and Witness 1 (RN Consultant). They acknowledged the findings. 2. Resident 1 was admitted to the facility in 12/2023 with diagnoses including left hemiplegia (weakness) and type 2 diabetes. The resident's current service plan, dated 05/12/25, progress notes dated 03/23/25 through 06/23/25, and corresponding incident reports were reviewed. Observations of the resident and interviews with staff were completed between 06/23/25 and 06/26/25. The following was identified: Resident 4's service plan was not reflective of the resident's current needs and/or lacked clear direction to staff in the following areas: * Incontinence of bowel and bladder; * Falls and interventions; * Pain, including location, how the resident expresses pain, and non-pharmacological interventions; * Smoking; * Interventions for behaviors including yelling; * Care of pet; * Assistance required for use of TV or phone; * Left sided paralysis; * Orthotic for left foot and ankle; * Personalized system for alerting staff when needing assistance; * Transfer pole; * Cleaning motorized wheelchair; and * Side rail. The need to ensure service plans reflected residents' current needs and provided clear direction to staff regarding the delivery of services was reviewed with Staff 1 (ED) and Staff 2 (Expressions Director) on 06/26/25 at 1:30 pm. They acknowledged the findings. 3. Resident 4 moved into the facility in 12/2023 with diagnoses including hypertension, ataxia (lack of coordination and balance), and schizophrenia. The resident's current service plan, dated 05/22/25, progress notes dated 03/23/25 through 06/23/25, and corresponding incident reports were reviewed. Observations of the resident and interviews with staff were completed between 06/23/25 and 06/26/25. The following was identified: Resident 4's service plan was not reflective of the resident's current needs and lacked clear direction to staff in the following areas: * Outside providers, including HH OT and PT; * Assistive devices used when outside of apartment versus inside apartment; * Fall history; * Self-administration of medication; and * Staff instructions and use of quarter-length side rails The need to ensure service plans reflected residents' current needs and provided clear direction to staff regarding the delivery of services was reviewed with Staff 1 (ED), Staff 2 (Expressions Director), and Witness 1 (RN Consultant) on 06/26/25 at 10:20 am. The findings were acknowledged. 4. Resident 3 moved into the assisted living facility in 04/2024 with diagnoses including major depressive disorder. The resident’s service plan dated 05/08/25 was reviewed, interviews with the resident and staff were conducted, and observations of the resident were made. The resident’s service plan was not reflective or did not provide clear direction to staff in the following areas: * Mental health issues and associated behaviors; * Chronic skin issues and interventions to promote skin integrity; * Interests/hobbies/social/leisure activities; * Communication needs and ability to be understood; and * Nutrition habits and fluid preferences. The need to ensure the service plan was reflective of the resident’s needs and preferences and provided clear direction regarding the delivery of services was discussed with Staff 1 (ED) and Staff 2 (Expressions Director) on 06/26/25 at 1:15 pm. They acknowledged the findings.

Items referenced to be out of compliance with OAR (C 260) will be addressed, corrected and facility will be in compliance by 8/25/25 by completing the following: • Resident #1, #3, & #4 services plans were reviewed and updated • Resident #2 no longer resides at Community • Licensed Nurse or Designee reviewed current resident service plans, addressing concerns identified •Designee re-educated ED, HSD, RCC and Med Techs on the requirement that service plans are readily available to staff, were reflective and provide clear direction to staff. Training also included how staff communicates updates or changed needed to service plan. • Licensed Nurse or Designee will audit 2 service plans per week for compliance weekly x 3 weeks then monthly x 2 months •The Administrator or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until compliance has been achieved as determined by the committee. • HSD/ED/Licensed Nurse is responsible

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 actions or interventions were determined for short-term changes of condition, the determined action or intervention was communicated to staff on all shifts, and progress was documented weekly until resolution for 3 of 3 sampled residents (#s 1, 2, and 4) who experienced short-term changes of condition. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 12/2023 with diagnoses including hypertension and schizophrenia. The resident's clinical record, including progress notes dated 03/23/25 through 06/23/25 and incident reports, was reviewed and interviews with staff were conducted. There was no documented evidence staff determined and documented actions or interventions, communicated actions or interventions to staff on all shifts, or monitored at least weekly until resolution for the following short-term changes of condition: * 04/29/25 – Fall in the shower with soreness to the right arm; * 05/03/25 – Allergic reaction to garlic, and resident was sent out to hospital; * 05/07/25 – Fall with bruising to the tops of feet and right arm pain; * 05/20/25 – Fall with right knee scrape and left ankle pain; * 06/06/25 – Intense muscle spasms; and * 06/16/25 – Gastrointestinal upset, diarrhea for four days. During an interview on 06/25/25 at 9:10 am, Staff 3 (RCC) confirmed there was no additional documentation related to the changes of condition for Resident 4. The need to ensure actions or interventions were determined and documented for short-term changes of condition, determined actions or interventions were communicated to staff on all shifts, and changes were monitored with weekly progress noted through resolution was discussed with Staff 1 (ED), Staff 2 (Expressions Director), and Witness 1 (RN Consultant) on 06/26/25 at 10:20 am. They acknowledged the findings. EX #2? Lindsay 2. Resident 2 was admitted to the facility in 06/2025 with diagnoses including Barrett’s esophagus with dysplasia (a precancerous condition of the esophagus) and protein calorie malnutrition. The resident’s record including progress notes dated 06/09/25 through 06/20/25 were reviewed and interviews with the resident and staff were conducted. There was no documented evidence the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved for the following changes of condition: * On 06/03/25, the resident moved into the facility; * On 06/12/25, a progress note indicated that care partners reported the wound located above the coccyx towards the left was getting worse; * On 06/13/25, a progress note indicated the facility RN and hospice RN had a joint visit and the facility RN would monitor the wound and apply honey on wound as needed; and * On 06/17/25, a progress note by the facility RN indicated that on “06/09/25 [hospice provider] note reviewed multiple sores on back, coccyx, right lower extremity, reposition frequently, barrier cream coccyx, red areas with every brief change and clothing change.” During an interview on 06/24/25 at 10:00 am, Witness 1 (RN Consultant) confirmed there was no additional documentation or skin monitoring for Resident 2’s changes of condition. The need to ensure resident-specific actions or interventions for 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 (ED), Staff 2 (Expressions Director) and Witness 1 on 06/26/25. They acknowledged the findings. 3. Resident 1 was admitted to the facility in 12/2023 with diagnoses including left hemiplegia (weakness) and type 2 diabetes. The resident's clinical record, including progress notes and incident reports dated 03/23/25 through 06/23/25 and the MAR dated 06/01/25 through 06/24/25, was reviewed, and interviews with staff were conducted. There was no documented evidence staff determined and documented actions or interventions, communicated actions or interventions to staff on all shifts, or monitored at least weekly until resolution for the following short-term changes of condition: * 05/30/25 - Broken bed; * 06/19/25 - Left forearm skin tear; and * Missed medications throughout 06/2025 including amlodipine (for hypertension), losartan (for hypertension), pantoprazole (for reflux), and polyethylene glycol (for constipation). During interviews on 06/24/25 and 06/25/25, Witness 1 (RN consultant) confirmed the facility did not currently have a process for determining and documenting interventions for short-term changes of condition and communicating those interventions to staff on all shifts. The need to ensure actions or interventions were determined and documented for short-term changes of condition, communicated to staff on all shifts, and changes were monitored with weekly progress noted through resolution was discussed with Staff 1 (ED) and Staff 2 (Expressions Director) on 06/26/25 at 1:30 pm. They acknowledged the findings.

Items referenced to be out of compliance with OAR (C 270) will be addressed, corrected and facility will be in compliance by 8/25/25 by completing the following: • Resident #4 & #1 short term changes of conditions noted were reviewed by RN, addressing concerns identified • Resident #2 no longer resides at Community • Licensed Nurse or Designee will review last 30 days of progress notes in combination with outside provider notes, addressing concerns identified • Designee re-educated ED and HSD on requirement to ensure actions or interventions were determined for short-term changes of condition, the determined action or intervention was communicated to staff on all shifts, and progress was documented weekly until resolution •Designee re-educated Direct Care Staff on short term changes on condition, training will include what to report, how to report and documentation • Licensed Nurse or Designee will review via SMART short term change of conditions verifying appropriate steps taken weekly x 3 weeks then monthly x 2 months •The Administrator or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until compliance has been achieved as determined by the committee. • HSD/ED/Licensed Nurse is responsible

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 for 1 of 1 sampled resident (#1) who experienced a significant change of condition. Findings include, but are not limited to: Resident 1 was admitted to the facility in 12/2023 with diagnoses including left hemiplegia (weakness) and type 2 diabetes. The resident’s record was reviewed, including the resident’s service plan and evaluation dated 05/12/25, weight records dated 03/2025 through 06/2025 and progress notes dated 03/23/25 through 06/23/25. Staff and the resident were interviewed, and the following was identified: The resident was noted to be able to eat independently. Staff stated the resident refused food at times due to nausea and upset stomach and had a PRN medication that s/he used at times. The resident required insulin to be provided on a sliding scale prior to meals. The resident’s weight records revealed the following: * 03/31/25 – 193.2 pounds; * 05/03/25 – 195.4 pounds; and * 06/03/25 – 175.6 pounds. Per survey request, the resident was weighed on 06/26/25 and weighed 182 pounds. Over a 30-day period, the resident experienced a weight loss of 19.8 pounds, or 10.1%. This constituted a severe weight loss and a significant change of condition, which required an RN assessment that included findings, resident status, and interventions made as a result of the assessment. There was no documented evidence an assessment had been completed. On 06/23/25 and 06/24/25, facility staff confirmed that an RN assessment had not been completed for the resident’s significant change of condition. The need to ensure an RN assessment was completed for all significant changes of condition was reviewed with Staff 1 (ED) and Staff 2 (Expressions Director) on 06/26/25 at 1:30 pm. They acknowledged the findings.

Items referenced to be out of compliance with OAR (C 280) will be addressed, corrected and facility will be in compliance by 8/25/25 by completing the following: •Resident #1 weights were assessed by RN, resident record updated. •Licensed Nurse or Designee will review for current residents last 30 days vitals, progress notes, outside provider notes, transfer to HLOC, skin deficits and PRN psychotropic use, addressing concerns identified • Designee re-educated ED and HSD on the requirement that an RN assessment is required for Significant Change of Condition • Licensed Nurse or Designee will review via SMART significant change of conditions verifying RN assessment completion weekly x 3 weeks then monthly x 2 months • HSD/ED/Licensed Nurse is responsible

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 outside providers left written information in the facility that addressed the on-site services provided and any clinical information necessary for facility staff to provide supplemental care for 2 of 4 sampled residents (#s 2 and 4) who received outside provider services. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 12/2023 with diagnoses including schizophrenia and generalized anxiety disorder. During the acuity interview on 06/23/25, the resident was identified as receiving HH services. Resident 4 was interviewed and one “Healthcare Provider Office Visit and Progress Notes/Orders” note dated 05/13/25 was reviewed. Additional documentation for outside provider visits that occurred between 05/13/25 and 06/23/25 was requested on 06/24/25. The facility provided faxed documentation dated 06/25/25 at 11:20 am from the HH PT and OT providers that indicated a total of seven visits occurred since Resident 4 was admitted to home health. The facility was unable to produce any “Healthcare Provider Office Visit and Progress Notes/Orders” for the remaining six visits. The need to ensure outside providers left written information in the facility that addressed the on-site services provided and any clinical information necessary for facility staff to provide supplemental care was discussed with Staff 1 (ED), Staff 2 (Expressions Director), and Witness 1 (RN Consultant) on 06/26/25 at 10:20 am. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 06/2025 with diagnoses including Barrett’s esophagus with dysplasia (a precancerous condition of the esophagus) and protein calorie malnutrition. During the acuity interview on 06/23/25, Resident 2 was identified as receiving hospice services. A review of the resident’s record showed there was no documented evidence that hospice was leaving written information at the facility that addressed the on-site services being provided to the resident, including any clinical information necessary for facility staff to provide supplemental care. In an interview on 06/25/25 at 2:30 pm, Staff 12 (MT) confirmed Resident 2’s hospice provider was not leaving documentation at the facility that addressed the services being provided. On 06/26/25, the need to ensure outside providers left written information in the facility that addressed the on-site services provided and any clinical information necessary for facility staff to provide supplemental care was discussed with Staff 1 (ED), Staff 2 (Expressions Director) and Witness 1 (RN Consultant). They acknowledged the findings.

Items referenced to be out of compliance with OAR (C 290) will be addressed, corrected and facility will be in compliance by 8/25/25 by completing the following: • Resident #4 reports from HH were reviewed, resident record updated. • Resident #2 no longer resides at Community. • Licensed Nurse or Designee identified residents receiving services from Hospice and Home Health Providers, requested and reviewed most recent visit documents, addressing concerns identified. • Designee re-educated ED, HSD, RCC on the requirement to ensure outside providers leave written information that address on-site services provided and any clinical information necessary for facility staff to provide supplemental care. • Licensed Nurse or Designee will review via SMART residents receiving HH and/or Hospice Services have applicable written information weekly x 3 weeks then monthly x 2 months. • HSD/ED/Licensed Nurse is responsible

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 411-054-0055 (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 observation, interview, and record review, it was determined the facility failed to ensure a safe medication and treatment system was in place and failed to ensure adequate professional oversight of the medication and treatment administration systems. Findings include, but are not limited to: During the re-licensure survey, conducted 06/23/25 through 06/26/25, administrative oversight of the facility's medication system was found to be ineffective based on deficiencies in the following areas: * C 302: Systems: Tracking Controlled Substances; * C 303: Systems: Medication and Treatment Orders; * C 305: Residents Right to Refuse; * C 310: Systems: Medication Administration; * C 325: Systems: Self-Administration of Medication; and * C 330: Systems: Psychotropic Medications. Failure to ensure a safe medication system and to ensure adequate professional oversight based on deficiencies related to medication administration was discussed with Staff 1 (ED), and Staff 2 (Expressions Director) on 06/26/25 at 1:15 pm. They acknowledged the findings.

Items referenced to be out of compliance with OAR (C 300) will be addressed, corrected and facility will be in compliance by 8/25/25 by completing the following: POC is POC for C302, C303, C305, C310, C325, C330

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 2 of 3 sampled residents (#s 1 and 2) whose MARs and controlled substance logs were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 06/2025 with diagnoses including Barrett’s esophagus with dysplasia (a precancerous condition of the esophagus) and protein calorie malnutrition. Resident 2 was prescribed PRN hydromorphone, two mg every three hours for severe pain or moderate pain. Resident 2's 06/03/25 through 06/23/25 MAR and the controlled substance log from 06/15/25 to 06/18/25 were reviewed. The following discrepancies were noted: * Staff documented the hydromorphone was administered on the MAR on two occasions, 06/10/25 and 06/13/25. There was no documented evidence on the Controlled Substance log the medication had been dispensed. Staff documented the hydromorphone was dispensed on the Controlled Substance log on 06/18/25. There was no documented evidence on the MAR the dispensed medication was administered to the Resident. Comparison of the medication dosing card to the disposition log showed the amount of medication left was reflected accurately on the distribution log. Inconsistencies between the MAR and controlled substance log were discussed on 06/26/25 with Staff 1 (ED), Staff 2 (Expressions Director) and Witness 1 (RN Consultant). They acknowledged the findings. 2. Resident 1 was admitted to the facility in 12/2023 with diagnoses including left hemiplegia (weakness) and type 2 diabetes. The resident’s record was reviewed, including MAR dated 06/01/25 through 06/23/25, controlled substance logs, and physician’s orders, and staff were interviewed. The following was identified: a. The resident’s MAR showed PRN hydrocodone (for pain), one tablet to be taken by mouth every six hours, was available for administration to the resident. The medication was not found on the medication cart or in the medication room as of 06/25/25. Staff identified the last time the medication was noted as removed from the controlled substance log as 03/08/25, and the medication was last ordered on 02/24/25. There was no documented evidence of the medication being discontinued or disposal of the medication. The resident stated s/he had not taken the medication since sometime in 03/2025. b. The resident had a signed physician’s order for PRN oxycodone (for pain), one tablet to be taken by mouth every 6 hours. The controlled substance log showed that on 06/11/25, one pill was documented on the log as removed, with no time noted. There was no corresponding date or time on the MAR to show that the medication was administered to the resident. The need to ensure the facility had a system for accurately tracking and disposing of controlled substances was reviewed with Staff 1 (ED) and Staff 2 (Expressions Director) on 06/26/25 at 1:30 pm. They acknowledged the findings.

Items referenced to be out of compliance with OAR (C 302) will be addressed, corrected and facility will be in compliance by 8/25/25 by completing the following: • Resident #1 MAR, controlled substance logs and physician orders were reviewed, addressing concerns identified. • Resident #2 no longer resides at Community • Licensed Nurse or Designee identified residents taking controlled substance and reviewed these medications via MAR, physician order and controlled substance log, addressing concerns identified. • Designee re-educated the HSD and ED on the requirements to accurately track and destroy controlled substances. • Designee re-educated Med Techs on Controlled substance administration • Licensed Nurse or Designee will conduct random audits via Documentation Review, Observation and/or Interview for Controlled Substance Compliance weekly x 3 weeks then monthly x 2 months. • HSD/ED/Licensed Nurse is responsible

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 and 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 medications and treatments the facility was responsible to administer for 3 of 4 sampled residents (#s 1, 2 and 4) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 12/2023 with diagnoses including left hemiplegia and type 2 diabetes. Resident 1’s signed physician orders and 06/01/25 through 06/23/25 MAR was reviewed. The following was identified: a. There was no documented evidence of a signed physician’s order which included dose and frequency for the following medications or treatments which were listed on the MAR: * Fungi-nail 1%, to be provided topically, one drop to the affected area every day for toenail fungus; and * Cyclobenzaprine, 10 mg, to be administered every eight hours as needed for muscle spasms. b. The resident had a signed physician’s order for Ensure, to be provided three times per day “in place of meal if not able to eat.” The Ensure was not listed on the resident’s MAR, and staff confirmed in an interview on 06/25/25 the resident did not have Ensure available to him/her in the medication room or his/her apartment. The need to ensure medication and treatment orders were carried out as prescribed and written, signed physician orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer was reviewed with Staff 1 (ED) and Staff 2 (Expressions Director) on 06/26/25 at 1:30 pm. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 06/2025 with diagnoses including Barrett’s esophagus with dysplasia (a precancerous condition of the esophagus) and protein calorie malnutrition. Resident 2’s signed physician orders and 06/03/25 through 06/23/25 MAR were reviewed. The following was identified: There was no documented evidence the facility had a written, signed order for hydromorphone two mg (for pain), administer one tablet twice daily in Resident 2's record. On 06/26/25, the need to ensure the facility had written, signed orders documented in the resident's record for all medications and treatments being administered was discussed with Staff 1 (ED), Staff 2 (Expressions Director) and Witness 1 (RN Consultant). They acknowledged the findings. 3. Resident 4 moved into the facility in 12/2023 with diagnoses including schizophrenia and generalized anxiety disorder. Resident 4’s signed physician orders and 06/01/25 through 06/23/25 MAR was reviewed. The following was identified: a. There were no written, signed orders for the following medications in Resident 4's record: * Rosuvastatin 20 mg (for high cholesterol) one tablet daily; * Quetiapine 25 mg (for schizophrenia) one tablet twice daily; * Quetiapine 50 mg (for schizophrenia) one tablet twice daily; and * Polyethylene glycol 17 grams (for constipation) daily as needed. b. The following medication orders were not carried out as prescribed: * Resident 4 had an order for baclofen 10 mg tab one tablet by mouth three times daily as needed for muscle spasms. However, it was marked as administered four times on 06/01/25 and 06/05/25 and five times on 06/16/25; and * Resident 4 had an order for clonazepam 0.5 mg one tab by mouth every night at bedtime as needed for anxiety/sleep. However, it was marked as administered two times on 06/06/25 and 06/18/25. The need to ensure physician orders were carried out as prescribed, and the facility had written, signed orders practitioner orders documented in the resident's facility record for all medications and treatments being administered was discussed with Staff 1 (ED), Staff 2 (Expressions Director), and Witness 1 (RN Consultant) on 06/26/25 at 10:20 am. They acknowledged the findings.

Items referenced to be out of compliance with OAR (C 303) will be addressed, corrected and facility will be in compliance by 8/25/25 by completing the following: • Resident #1 & #4 orders were reviewed and sent to MD for review and signature. • Resident #2 no longer resides at Community • Licensed Nurse or Designee reviewed current resident orders, sent to MD for signature • Designee re-educated the HSD and ED on the requirement that orders need be carried out as prescribed. • Designee re-educated Med Techs on three folder system • Licensed Nurse or Designee will review orders via SMART for compliance weekly x 3 weeks then monthly x 2 months • HSD/ED/Licensed Nurse is responsible

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 or other practitioner when a resident refused to consent to orders for 2 of 2 sampled residents (#s 1 and 3) who had documented medication refusals. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 04/2024 with diagnoses including major depressive disorder and gastroesophageal reflux disease. Resident 3's clinical records and MARs were reviewed during the survey and revealed the resident had multiple medication refusals from 06/01/25 through 06/23/25. The medications refused included: * Quetiapine 50 mg for anxiety/agitation, refused on five occasions; and * Guaifenesin 600 mg for cough, refused on one occasion. There was no documented evidence the physician had been notified of the resident’s refusals until after survey entrance on 06/23/25. On 06/26/25 at 1:15 pm the need to ensure the physician or other practitioner was notified each time a resident refused to consent to an order was discussed with Staff 1 (ED) and Staff 2 (Expressions Director). They acknowledged the findings. 2. Resident 1 was admitted to the facility in 12/2023 with diagnoses including left hemiplegia (weakness), type 2 diabetes, and neurogenic bowel (constipation and/or incontinence of bowels). The resident’s MAR, dated 06/01/25 through 06/24/25, and physician’s orders were reviewed. The resident had an order for polyethylene glycol to be administered once per day for bowel care. The facility documented that the resident refused the medication 16 times during the reviewed time period. There was no documented evidence that the physician was notified until after survey entrance on 06/23/25. The need to ensure the physician was notified when a resident refused to consent to an order was reviewed with Staff 1 (ED) and Staff 2 (Expressions Director) on 06/26/25 at 1:30 pm. They acknowledged the findings.

Items referenced to be out of compliance with OAR (C 305) will be addressed, corrected and facility will be in compliance by 8/25/25 by completing the following: •Resident #1 and #3 last 30 day refusals were reviewed and communicated to their physician. •Licensed Nurse or Designee reviewed current residents’ refusals for the last 2 weeks, addressing concerns identified. • Designee re-educated ED, HSD, RCC and Med Techs on the requirement to notified physician when a resident refuses medications. • Licensed Nurse or Designee will conduct random audits for refusal notification compliance via documentation review, observation, and/or interview weekly x3 weeks then monthly x 2 months. • HSD/ED/Licensed Nurse is responsible

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 an accurate MAR was kept related to the initials of the person administering the medication, and failed to ensure resident-specific parameters and instructions were included for PRN medications for 3 of 4 sampled residents (#s 1, 2 and 4) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 12/2023 with diagnoses including left hemiplegia (weakness) and type 2 diabetes. The resident’s MAR, dated 06/01/25 through 06/24/25, physician’s orders, and delegation records were reviewed, and staff were interviewed. The following was identified: a. During an interview on 06/24/25, Staff 1 (ED) stated that MTs had been administering medications while using other MTs initials to document in the MAR due to difficulty logging into the electronic system. This resulted in an inaccurate MAR related to administration of the following medications: *Lantus insulin injection (for type 2 diabetes) on two occasions; *Humalog insulin injection (for type 2 diabetes) on 10 occasions; and *Oxycodone (for pain) on four occasions. b. The resident had three PRN medications for pain which did not have resident-specific parameters for order of administration: *Hydrocodone 10 mg, one tablet every six hours; *Oxycodone 5 mg, one tablet every six hours; and *Acetaminophen 325 mg, two tablets every four hours. The need to ensure the MAR was accurate and that PRN medications included resident-specific parameters and instructions for administration was reviewed with Staff 1 and Staff 2 (Expressions Director) on 06/26/25 at 1:30 pm. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 06/2025 with diagnoses including Barrett’s esophagus with dysplasia (a precancerous condition of the esophagus) and protein calorie malnutrition. Resident 2's 06/03/25 through 06/23/25 MAR was reviewed and identified the following: * Several medications on the MAR had duplicate orders; and * Two PRN bowel medications to treat constipation lacked parameters on when to initiate treatment and which medication to administer first. The above information was shared with Staff 1 (ED), Staff 2 (Expressions Director) and Witness 1 (RN Consultant) on 06/26/25. They acknowledged the findings. 3. Resident 4 moved into the facility in 12/2023 with diagnoses including schizophrenia and generalized anxiety disorder. The resident's 06/01/25 through 06/23/25 MAR and physician's orders were reviewed. The following PRN medications lacked resident-specific parameters or instructions to direct non-licensed staff on which medication should be administered and in what order: * Clonazepam and melatonin for sleep; and * Hydrocodone-acetaminophen, lidocaine cream, and acetaminophen for pain. During an interview on 06/25/25 at 10:40 am, Staff 12 (MT) confirmed there were no parameters on which medication should be administered and in what order listed for staff on the computer MAR. The need to ensure the resident's MAR was accurate and included resident-specific parameters and staff instructions was reviewed with Staff 1 (ED), Staff 2 (Expressions Director), and Witness 1 (RN Consultant) on 06/26/25 at 10:20 am. They acknowledged the findings.

Items referenced to be out of compliance with OAR (C 310) will be addressed, corrected and facility will be in compliance by 8/25/25 by completing the following: •Resident #1 & #3 PRN medications were reviewed for resident specific parameters and instructions •Resident #2 no longer resides at Community •Licensed Nurse or Designee reviewed current resident PRN medications for resident specific parameters and instructions, addressing concerns identified •Licensed Nurse or Designee re-educated MTs on the requirement that log-ins cannot be shared •Designee re-educated the HSD on the requirement that PRN medications require resident specific parameters and instructions. •Licensed Nurse or Designee will review new orders via SMART for resident specific parameters and instructions weekly x 3 weeks then monthly x 2 months •Licensed Nurse or Designee will audit login compliance via random audits via observation or staff interview weekly x 3 week or monthly x 2 months •HSD/ED/Licensed Nurse is responsible

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 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications were evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications and ensure a physician's or other legally recognized practitioner’s written order was in place for the self-administration of prescription medications for 1 of 1 sampled resident (# 4) who self-administered medication. Findings include, but are not limited to: Resident 4 moved into the facility in 12/2023 with diagnoses including hypertension, schizophrenia, and a history of several food allergies. Review of Resident 4’s physician’s orders and MAR dated 06/01/25 through 06/23/25, and progress notes dated 03/23/25 through 06/23/25 revealed the resident self-administered one of his/her PRN medications. a. During an interview on 06/24/25 at 1:15 pm, Resident 4 stated s/he self-administered one medication. The medication was observed and lacked corresponding orders to self-administer: * Epinephrine 3 mL pen (for anaphylactic symptoms). An order for the prescription medication to be self-administered was requested on 06/24/25 and 06/25/25. The facility was unable to provide the requested physician's order prior to survey exit. b. The resident's quarterly self-administration evaluation was requested. On 06/25/25 at 11:20 am, Witness 1 (RN Consultant) confirmed there was no previous or current self-administration evaluation to support the resident was safe to self-administer medications. Witness 1 provided surveyor with a self-administration evaluation completed on 06/25/25. The need to ensure residents who chose to self-administer medications were evaluated for safety and had a physician's written order of approval for the self-administration of prescription medications was discussed with Staff 1 (ED), Staff 2 (Expressions Director), and Witness 1 on 06/26/25 at 10:20 am. They acknowledged the findings.

Items referenced to be out of compliance with OAR (C 325) will be addressed, corrected and facility will be in compliance by 8/25/25 by completing the following: • Resident #4 orders were reviewed, evaluation completed and applicable orders obtained for self-administration of medication •Licensed Nurse or Designee will review current residents for Self-administration orders and evaluations, addressing concerns identified • Designee re-educated ED, HSD and Med Techs on the requirements that a self administration evaluation and physician order is required. • Licensed Nurse or Designee will do audits on self-administration via documentation review, observation and/or staff/resident interview for compliance weekly x 3 week then monthly x 2 months • HSD/ED/Licensed Nurse is responsible

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

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications had written, resident-specific parameters and staff had documented non-drug interventions had been tried with ineffective results prior to administering PRN psychotropic medications for 3 of 3 sampled residents (#s 2, 3 and 4) who were prescribed PRN psychotropics. Findings include, but are not limited to: Resident 2 was admitted to the facility in 06/2025 with diagnoses including Barrett’s esophagus with dysplasia (a precancerous condition of the esophagus) and protein calorie malnutrition. Review of the resident's 06/03/25 through 06/23/25 MAR and current physician orders identified an order for lorazepam one mg (a psychotropic medication), one tablet every two hours as needed for agitation or dyspnea. The facility administered the lorazepam to the resident on three occasions between 06/03/25 and 06/23/25. The MAR lacked resident-specific parameters for staff describing how the resident expressed agitation, and there was no documentation of what non-drug interventions were to be attempted prior to administration of the medication. The need to ensure resident-specific parameters and documentation of non-pharmacological interventions to try and document as ineffective prior to administering PRN psychotropics was discussed with Staff 1 (ED), Staff 2 (Expressions Director) and Witness 1 (RN Consultant) on 06/26/25. They acknowledged the findings. 2. Resident 3 moved into the assisted living facility in 04/2024 with diagnoses including major depressive disorder and gastroesophageal reflux disease. Review of Resident 3's MAR, dated 06/01/25 through 06/23/25, and physician orders revealed the following: The resident was prescribed lorazepam (sedative to treat anxiety), 0.5 mg every two hours as needed for anxiety. It was documented as administered to the resident on three occasions between 06/01/25 and 06/23/25. * The MAR did not provide instructions to non-licensed staff regarding how the resident demonstrated signs and symptoms of anxiety behaviors for which staff could consider administering the medication; and * There were no resident-specific non-pharmacological interventions. The need to have written, resident-specific parameters for PRN psychotropic medications, and to have non-drug interventions for staff to attempt and document ineffective results prior to administration of the psychotropic medications, was reviewed with Staff 1 (ED) and Staff 2 (Expressions Director) on 06/26/25 at 1:30 pm. They acknowledged the findings. 3. Resident 4 moved into the facility in 12/2023 with diagnoses including schizophrenia and generalized anxiety disorder. Review of Resident 4's MAR, dated 06/01/25 through 06/23/25, and physician orders revealed the following: Resident 4 was prescribed PRN clonazepam for anxiety or sleeplessness, and it was documented as administered to the resident on 19 occasions between 06/01/25 and 06/23/25. There was no documentation which indicated why the medication had been administered or that non-pharmacological interventions had been attempted without success prior to administration. During an interview on 06/25/25 at 10:40 am, Staff 12 (MT) confirmed there were no non-pharmacological interventions listed or how the resident exhibited anxiety on the computer MAR. The need to ensure the MAR included a description of how the resident exhibited anxiety and non-pharmacological interventions to attempt prior to administering the PRN psychotropic medication was discussed with Staff 1 (ED), Staff 2 (Expressions Director), and Witness 1 (RN Consultant) on 06/26/25 at 10:20 am. They acknowledged the findings

Items referenced to be out of compliance with OAR (C 330) will be addressed, corrected and facility will be in compliance by 8/25/25 by completing the following: •Resident #3 and #4 PRN psychotropics were reviewed, record updated •Resident #2 no longer resides at Community. •Licensed Nurse or Designee reviewed PRN psychotropic medications for current residents, addressing concerns identified. •Licensed Nurse or Designee will audit PRN Psychotropic medications via documentation review and/or staff interview/observations weekly x 3 weeks then monthly x 2 months •HSD/ED/Licensed Nurse is responsible

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by:

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by: ?Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed by an RN, PT, or OT; failed to document other less restrictive alternatives evaluated prior to the use of the device; and failed to instruct caregivers on the correct use and precautions related to the use of the device for 4 of 4 sampled residents (#s 1, 2, 3 and 4) who had side rails. Findings include, but are not limited to: During the entrance conference at 1:30 pm on 06/30/25, staff identified Residents 1, 2, 3 and 4 as having side rails. Staff stated that at times, the rails were used to keep residents from rolling out of bed. Residents 1, 2, 3 and 4 were observed throughout the survey, dated 06/23/25 through 06/26/25, to have side rails on one or both sides of their beds. There was no documented evidence the following required elements were completed related to the side rails: * Assessment by facility RN, PT, or OT; * The facility documented other less restrictive alternatives evaluated prior to the use of the device; and * The facility had instructed caregivers on the correct use and precautions related to the use of the device. The need to ensure the use of a supportive device with potentially restraining qualities was assessed by an RN, PT, or OT, other less restrictive alternatives were evaluated prior to the use of the device and caregivers were instructed on the correct use and precautions related to the device was discussed with Staff 1 (ED) and Staff 2 (Expressions Director) on 06/26/25. They acknowledged the findings.

Items referenced to be out of compliance with OAR (C 340) will be addressed, corrected and facility will be in compliance by 8/25/25 by completing the following: •Resident #1, #3, & #4 use of side rails was reviewed by RN, addressing concerns identified •Resident #2 no longer resides at Community •Licensed Nurse or Designee identified residents with restraints and supportive devices and reviewed, addressing concerns identified. •Designee re-educated ED and HSD on the requirements for Restraints and Supportive Devices; assessment, less restrictive alternatives evaluate prior to use of device, instructions for caregivers on correct use and precautions related to the use of the device •Licensed Nurse or Designee will do random audits on Restraints/Supportive Devices via documentation review, observation and/or staff interview for compliance weekly x 3 weeks then monthly x2 months •HSD/ED/Licensed Nurse is responsible

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by:

OAR 411-054-0070 (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 observation, 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, including a minimum of two direct care staff scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs. Findings include, but are not limited to the following: As of survey entrance on 06/23/25, the facility had a census of 36 residents. Five of the residents required two staff members’ assistance for all transfers and care, and two residents required feeding assistance in their rooms, one on one, during all meals. During an interview on 06/24/25 at 10:25 am, Staff 1 (ED) stated that the facility employed universal workers. The facility's posted staffing plans, the staffing schedule from 06/12/25 through 06/23/25, and the corresponding timeslips were reviewed. The facility's posted staffing plan indicated six direct care staff were scheduled on day shift, five direct care staff on swing shift, and three direct care staff on the overnight shift. During an interview on 06/24/25 at 10:25 am, Staff 1 stated that the current staffing plan was meant to staff to the facility’s calculated ABST needs. She stated the facility did not currently staff over the calculated ABST needs to account for unscheduled needs or universal workers. Upon review of the facility’s timeslips, it was found that the facility failed to staff to the posting staffing plan 48% of the time, including 91% of the time on overnight shifts. During 36% of the reviewed overnight shifts, the facility failed to have at least two direct care staff available at all times to meet the needs of residents requiring two staff for assistance with transfers and care. The need to have a sufficient number of staff to meet all scheduled and unscheduled needs of residents, including a minimum of two direct care staff scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs, was reviewed with Staff 1 and Staff 2 (Expressions Director) on 06/26/25 at 1:30 pm. They acknowledged the findings.

Items referenced to be out of compliance with OAR (C 360) will be addressed, corrected and facility will be in compliance by 8/25/25 by completing the following: •No Residents Cited •ED or Designee will review ABST, current staff posting, residents requiring 2 person assist, residents that require feeding assist, and current schedule, addressing concerns identified • Designee will re-educated ED on the requirement to have sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident, including a minimum of two direct care staff scheduled and available at all times whenever a resident requires assistance of two direct care staff for scheduled and unscheduled needs. •ED or Designee will review staffing, ABST and Staff posting for compliance x 3 weeks then monthly x 2 months •ED is responsible

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 (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) evaluation was updated and reviewed before a resident moved in, no less than quarterly at the same time of service plan update, and/or with a significant change of condition for 4 of 4 sampled residents (#s 1, 2, 3, and 4) and three unsampled residents. Findings include, but are not limited to: The facility’s ABST was reviewed on 06/23/24 at 1:30 pm. The following was identified: a. Four residents, including Resident 2 and three unsampled residents, did not have an ABST evaluation completed. The residents moved into the facility between 05/08/25 and 06/03/25. b. Resident 1’s ABST was not updated after s/he experienced a significant change of condition related to weight loss on 06/03/25. c. Resident 1, 3 and 4’s ABST evaluations did not have evidence they were updated quarterly at the same time as the service plan update. The need to ensure residents’ ABST evaluations were updated before move-in, with significant changes of condition, and no less than quarterly with the service plan was discussed with Staff 1 (ED) and Staff 2 (Expressions Director) on 06/26/25 at 1:30 pm. They acknowledged the findings.

Items referenced to be out of compliance with OAR (C 363) will be addressed, corrected and facility will be in compliance by 8/25/25 by completing the following: •ABST was updated for Resident #1, #3, & #4 •Resident #2 no longer resides at Community •ED or Designee completed ABST evaluation for current residents. •Designee trained ED on the requirement to ensure ABST is updated before a resident moves in, no less than quarterly at the time of the service plan update and/or with a significant change of condition. •ED or Designee will audit ABST for compliance weekly x 3 weeks then monthly x 2 months •ED is responsible

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

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired staff (#s 13 and 14) demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 06/25/25. There was no documented evidence Staff 13 (MT) and Staff 14 (CG), hired 04/15/25, 05/06/25, respectively, demonstrated competency in all assigned job duties within 30 days of hire in one or more of the following areas: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation, and reporting of changes of condition; * Conditions which require assessment, treatment, observation, and reporting; * General food safety, serving and sanitation; and * First aid/abdominal thrust. The need for staff to demonstrate competency in their assigned job duties within 30 days of hire was discussed with Staff 1 (ED) and Staff 2 (Expressions Director) on 06/26/25. They acknowledged the findings.

Items referenced to be out of compliance with OAR (C 372) will be addressed, corrected and facility will be in compliance by 8/25/25 by completing the following: •Staff 13 (MT) hired 4/15/2025, training was completed •Staff 14 (CG) hired 5/6/2025, training was completed •ED or Designee identified current staff newly hired last 6 months reviewing first 30 days training, addressing concerns identified •Designee re-educated ED, Office Manager, RCC and HSD on training requirements w/in 30 days of hire •ED or designee will audit new hires verifying in compliance with first 30 days training requirements weekly x 3 weeks then monthly x 2 months •ED is responsible

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by:

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: ?Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with the Oregon Fire Code (OFC) and fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to: Fire and life safety records, reviewed between 12/2024 and 06/2025, showed fire drills were not conducted every other month and drill documentation was lacking in the following areas: * Date and time of fire drill; * Location of simulated fire origin; * Escape route used; * Problems encountered, comments related to residents who resisted or failed to participate in the drills; * Evacuation time-period needed; * Staff members on duty and participating; and * The number of occupants evacuated. Additionally, the records reviewed did not show life safety training was provided on alternating months from the fire drills. The need to ensure all required components were addressed and documented for each fire drill and fire and life safety instruction was provided to staff on alternate months, in accordance with the OFC, was discussed with Staff 1 (Executive Director) and Staff 7 (Maintenance Director) on 06/25/25. They acknowledged the findings.

Items referenced to be out of compliance with OAR (C 420) will be addressed, corrected and facility will be in compliance by 8/25/25 by completing the following: •Fire Drill was conducted •Fire and Life Safety Training was completed •ED re-educated the maintenance director on the requirement to conduct a fire drill every other month at different times of the day, evening and night shifts with Fire and Life instruction to staff must be provided on alternate months •ED or Designee will audit fire drill and/or fire and lift instruction for compliance monthly x 3 months •ED is responsible

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

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: ?Based on interview and record review, it was determined the facility failed to ensure residents were instructed on fire and life safety procedures within 24 hours of admission and re-instructed, at least annually. Findings include, but are not limited to: Fire and life safety records were requested and reviewed with Staff 1 (ED) and Staff 7 (Maintenance Director) on 06/25/25 and the following deficiencies were identified: * There was no documented evidence of instruction to residents on general safety procedures, evacuation methods, responsibilities during a fire, and designated meeting places inside or outside the building in the event of an actual fire within 24 hours of admission; and * There was no documented evidence of fire and life safety training provided to residents at least annually. The need to ensure residents received fire and life safety training within 24 hours of admission and at least annually was discussed with Staff 1 and Staff 7 on 06/25/25. They acknowledged the findings.

Items referenced to be out of compliance with OAR (C 422) will be addressed, corrected and facility will be in compliance by 8/25/25 by completing the following: •Current Residents were instructed on Fire and Life Safety Procedures • Designee re-educated the ED on the requirements to ensure residents are instructed on Fire and Life Safety Procedures w/in 24 hours of admission and re-instructed at least annually •ED or Designee will Audit new Move Ins for fire life safety instruction weekly x 3 weeks then monthly x 2 months •ED is responsible

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

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory care communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: ?Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses to common-use areas were maintained in good repair and the grounds were kept orderly and free of litter and refuse. Findings include, but are not limited to: The exterior of the facility was toured on 06/23/25. The following was identified: * The interior courtyard sidewalk had areas in front of the two trees and near the activity room that were damaged and created tripping hazards; * The sidewalk outside of the nurse’s station, in between the ALF and MCC, was damaged and created a tripping hazard; * Facility grounds including the main courtyard’s lawn, landscaping, and pet area were overgrown with weeds and high grass; and * In the interior courtyard, there was a build-up of dust and debris along the columns and sitting area with the awning. On 06/25/25 at 9:30 am, the building's exterior was toured with Staff 1 (ED) and Staff 7 (Maintenance Director). They acknowledged the findings.

Items referenced to be out of compliance with OAR (C 610) will be addressed, corrected and facility will be in compliance by 8/25/25 by completing the following: •A vendor has been contracted with to grind down the concrete on the Interior Courtyard sidewalk areas in front of the two trees and near the activity room. •A vendor has been contracted with to grind down the concrete on the sidewalk outside of the nurses station in between AL and MCC. •A vendor has been contracted with to service the facility grounds including the main courtyards lawn, landscaping and pet area were overgrown with weeds and high grass. •Interior Courtyard build up of dust and debris along the columns and sitting area with the awning was addressed. •ED or Designee walked community exterior pathways, accesses to common-use areas and grounds, addressing concerns identified. •ED or Designee re-educated the Maintenance Director on the requirement to ensure the grounds, exterior pathways and accesses to common use areas are well maintained. •ED or Designee will audit exterior pathways/accesses to common use areas and grounds for compliance weekly x 3 weeks then monthly x 2 months. •ED is responsible

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 clean and maintained in good repair. Findings include, but are not limited to: The facility was toured on 06/23/25 and the following was observed: a. Facility-wide: * Multiple stains on the carpet throughout resident-use corridors and entryway with larger stains observed in the entryway, front of the library, and near Rooms 101, 102, 11, 115, and 149; and * The fish tank near the entryway had a build-up of dust and debris; and * The popcorn maker in the library had a build-up of an oily substance throughout the interior. b. Laundry Room: * The wall behind the sink had chipped and peeling paint. c. Room 102: * There was a pervasive unpleasant odor in the room; * There was a build-up of black matter and water underneath a plastic covering to the entryway linoleum; and * The bedroom wall was gouged and chipped. d. Exterior of building * Pillars in the interior courtyard and entryway were in need of painting and repair; and * There was peeling paint and exposed wood underneath the windows of Room 119 and Room 120 in the interior courtyard. The above areas were toured with Staff 1 (ED) and Staff 7 (Maintenance Director) on 06/25/25 at 9:20 am. They acknowledged the findings.

Items referenced to be out of compliance with OAR (C 613) will be addressed, corrected and facility will be in compliance by 8/25/25 by completing the following: •The carpet stains were cleaned. The Community contracted with a vendor to replace the carpet in the entryway area. •The Dust and Debris on Fishtank near entryway was cleaned •The Popcorn maker was cleaned. •The wall behind sink in laundry room was repaired •Room 102 floor was cleaned, plastic covering removed, bedroom wall repaired. Community contracted with vendor to replace flooring in Room 102. •The Pillars on exterior of building were repaired. •The ED or Designee walked the community for cleanliness and good repair, addressing concerns identified. •The ED re-educated the maintenance director on the requirement to ensure the community stays clean and in good repair. •The ED or Designee will do rounds on the community for cleanliness and good repair weekly x 3 weeks then monthly x 2 months •ED is responsible

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 facility. Findings include, but are not limited to: During the survey, the facility was identified to have five doors that exited into the facility's inner courtyard and four doors exiting to the exterior of the building. Only one exit door, near Room #152, had an alarming device to alert staff when residents left the building. On 06/25/25 at 9:30 am, the building was toured with Staff 1 (ED) and Staff 7 (Maintenance Director). They acknowledged the findings regarding the lack of an alarming device or other acceptable systems to alert staff when residents exited the facility.

Items referenced to be out of compliance with OAR (C 613) will be addressed, corrected and facility will be in compliance by 8/25/25 by completing the following: •The four doors cited that exit to the exterior of the building now alarm •ED or Designee reviewed the Community exit doors for alarming devices, addressing concerns identified. •ED or Designee re-educated the maintenance director on the requirement to ensure exit doors were equipped with an alarming device •ED of Designee will audit exit door for alarm device compliance weekly x 3 weeks then monthly x 2 months •ED is responsible

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:

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

• No POC refer to C252

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