Print Inspection: RL005815

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 initial move-in evaluations included all required elements for 1 of 1 sampled resident (#3) whose evaluation was reviewed. Findings include, but are not limited to: Resident 3 was admitted to the facility in 04/2025 with diagnoses including hypertension. Resident 3's move-in evaluation was completed on 04/30/25, and failed to address the following required elements: * Spiritual and cultural preferences and traditions; * List of medications and PRN use; * Personality, including how the person copes with change or challenging situations; * Nutrition habits, including fluid preferences; * Recent losses; * Unsuccessful prior placements; and * Environmental factors that impact the resident’s behavior including, but not limited to: noise, lighting, and room temperature. On 07/30/25, the need to ensure the initial evaluation addressed all required elements prior to the resident's admission was reviewed with Staff 1 (ED). She acknowledged the findings.

Items identified as out of compliance with OAR C252 will be addressed and corrected. The facility will return to full compliance by September 28, 2025, through the following actions: 1. Evaluation for resident #3 updated to be resident centered, including needs and preferences to support focus, goal, and interventions. Current resident quarterly evaluations and service plans will be reviewed and revised by 9/28/25.Resident #3’s evaluation has been updated with individualized, resident-centered information and now reflects all requested elements.-Before moving and when updated including the following information legal name for billing purposes, pronouns, gender identity, prior living arrangements, emergency contacts, Service plan involvement regarding resident, family and social support. Financial and other legal relationships, advanced directive, guardianship, Conservatory ship, POA, primary language, community connection and health and social service providers. A Licensed Nurse or designee will review move-in evaluations for residents admitted within the past 60 days, ensuring all required elements are addressed and missing information is requested as available. 2. Evaluations will be reviewed in collaboration with the resident, their designee, direct care staff, and the Licensed Nurse to ensure ongoing accuracy and inclusion of all required elements, including the resident’s current preferences. 3. ED, RCC, Designee will update LN with any change of condition requiring assessment. RN will provide review of all updated service plans weekly. LN will provide evaluation for new move ins and coordinate move in evaluation for compliance to support resident needs with all new move ins.Evaluations will be completed prior to move-in, reviewed again at the time of move-in, within 30 days, quarterly, and as needed with any change of condition. The Executive Director and RCC will conduct daily monitoring (Monday–Friday) through the SMART [Systems Monitoring & Resident Tracking] meetings. A licensed nurse will complete weekly reviews to ensure evaluations are completed timely. Additionally, the PCC evaluation schedule has been updated to accurately track due and upcoming evaluations. 4. The Executive Director, Resident Care Coordinator, or designee will oversee completion, accuracy, and ongoing compliance with evaluation and service plan requirements.

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 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to provide health services and have systems in place to respond to the 24-hour care needs of residents including an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility; and ensure a significant change of condition assessment was completed by the RN, which included findings, resident status, and interventions, for 1 of 3 sampled residents (# 1) who experienced significant changes of condition for weight gain and two pressure ulcers. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 04/2023 with diagnoses including chronic kidney disease and spinal stenosis. Observations of the resident during the survey from 07/28/25 through 07/30/25 revealed Resident 1’s legs were edematous and his/her feet and toes were purple in color at times when resting on the floor. The majority of observations during the survey were of the resident elevating his/her feet and legs. The resident's clinical record was reviewed, including 01/09/25 through 07/22/25 weight records, 05/29/25 service plan, 07/01/25 through 07/28/25 MARs, 04/11/25 through 07/28/25 progress notes, and temporary service plans (TSPs). The resident was observed, and interviews with the resident and staff were conducted. The following was identified: a. Resident 1’s weight records noted the following: * 04/10/25 - 169 pounds; and * 05/11/25 – 179.4 pounds; Resident 1 gained 10.4 pounds, which constituted a severe weight gain of 5.26% of his/her body weight in one month, was considered severe, and triggered a significant change of condition. There was no documented evidence an RN assessment of the severe weight gain had been completed. In a phone interview on 07/29/25 at 1:25 pm with Staff 3 (RN), she confirmed she was aware of Resident 1’s weight being “all over the place, but stable.” She reported an RN assessment had been completed on 4/13/25. The 04/13/25 document was an RN assessment for admission to hospice and had no information regarding Resident 1’s weight loss or gain. No further documentation was provided. b. On 06/09/25, a TSP revealed Resident 1 had “four small bedsores in the crease of [his/her] buttocks, Hospice has been notified.” Instructions to staff were to “adjust pressure every 2-3 hours”. A progress note on 06/10/25 indicated, “Areas are open, no bleeding or pain expressed.” A “Wound 1 Evaluation” was completed by Staff 3 on 06/18/25. The evaluation noted the “Pressure Ulcer Stage Date” as 06/18/25 and classified the wounds as a Stage 2, nothing the “wound is now healed.” There was no additional documentation to indicate an RN assessment had been completed prior to 06/18/25 that included findings, resident status, and interventions made as a result of the assessment prior to 06/18/25. A progress note from 07/02/25 revealed the “bedsores are completely healed and skin is closed and intact...being taken off alert at this time.” c. On 7/16/25 a TSP revealed “reopen [sic] sores near buttocks…some bleeding pressure sore [sic]” with instructions from hospice to leave a sacral bandage over the sore for five days unless soiled. Resident 1 experienced a second pressure sore to his/her buttocks on 07/16/25. The pressure sore, identified on 07/16/25, was a significant change of condition that required an RN assessment. In a phone interview on 07/29/25 at 1:25 pm, Staff 3 acknowledged she completed an RN assessment on 07/28/25 and included findings, resident status, and interventions made as a result of the assessment. She reported that the wound was healing and documented the pressure ulcer was at a Stage 1. The pressure sore indicated a significant change a condition and required a timely RN assessment that included findings, resident status, and interventions made as a result of the assessment prior to 07/28/25. 2. During the survey, from 07/28/25 through 07/30/25, it was disclosed the facility used an RN who was available by phone but only visited on-site quarterly. In a phone interview on 7/29/25 at 1:25 pm with Staff 3, she confirmed she was last in the building on 5/29/25 and is scheduled again on 08/27/25. “I am usually there for a day, about 8-12 hours, but available by phone.” This was confirmed on 7/29/25 by Staff 1 (ED). In an interview on 07/29/25 with Staff 1, she acknowledged, “I do not have a pharmacy background and neither does my RCC,” and stated they do not have a nurse, LPN or RN, who worked in the building other than the RN who was available by phone and in the facility for one day quarterly. She acknowledged the need for increased on-site visits to address the acuity needs of the residents. During the survey, from 07/28/25 through 07/30/25, Staff 2 LPN/Health Services Director was present for support during the survey but did not provide regular hours in the facility. The need to ensure all significant changes of condition were assessed by an RN, as well as ensuring they were completed in a timely manner, with documented findings, resident status, and interventions made as a result of the assessment, and ensure a system was in place that included an Oregon licensed nurse who was regularly scheduled for onsite duties was discussed with Staff 1 (ED) on 07/30/25. She acknowledged the findings. No further information was provided.

Items identified as out of compliance with OAR C280 will be addressed and corrected. The facility will return to full compliance by September 28, 2025, through the following actions: 1. Resident #1’s weights have been assessed by the RN and the resident’s record has been updated. A skin deficit audit is being completed to review all actual and potential skin concerns. 2. A Licensed Nurse or designee will review the past 30 days of records for current residents, including vitals, progress notes, outside provider notes, transfers to higher levels of care, skin deficits, and PRN psychotropic use. Identified concerns will be addressed promptly. o The designee re-educated the Executive Director and Resident Care Coordinator on the requirement that an RN assessment must be completed for all significant changes of condition. o A Licensed Nurse or designee will review significant changes of condition via SMART (clinical meeting), verifying RN assessment completion weekly for three weeks, then monthly for two months. o HIPAA-compliant video conferencing between the RN and community designee/RCC will occur weekly to review RN-specific needs in the community. Newly identified changes of condition will be communicated to the Licensed Nurse/RN within 24 hours via secure text or email. o RN will be in the community 20 hours weekly and continue to be available by phone 24 hours a day. o On 8/19/25, an educational in-service was provided to Med-Techs, RCC, and ED on the following topics: recognizing and reporting resident condition changes, Med-Tech daily routines, shift-to-shift reporting, eMAR review, short-term health monitoring and service plan addendums, order flow process, and incident reporting. 3. Med-Techs, RCC, or designees will record all identified changes of condition in the standardized RN Communication Log. This log will be reviewed with the RN during the weekly call. 4. The RCC, ED, or Licensed Nurse is responsible for oversight, compliance, and follow-up related to these corrective actions.

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

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled resident (# 1) whose MARs and Controlled Substance Disposition logs were reviewed. Findings include, but are not limited to: Resident 1 was admitted to the facility in 04/2023 with diagnoses including chronic kidney disease and spinal stenosis. Observations of the resident, interviews with staff, and record review were completed. The resident's signed physician orders from 05/19/25 and 07/10/25, and the resident's Controlled Substance Disposition logs and MARS, reviewed from 07/01/25 through 07/28/25, showed the following: a. Methadone HCl 5 mg, give 1.5 tablets every morning: * On 07/14/25 the disposition log showed one dose was signed out at 8:00 am and a second dose at 8:47 pm. The resident did not have an evening dose of 1.5 tablets and an administration was not reflected on the MAR; and * A dose was signed on the MAR on 07/27/25 but not reflected in the disposition log. b. Methadone HCl 5 mg, give 2.5 tablets every night at bedtime: * A dose was signed on the MAR on 07/14/25 at bedtime but not reflected on the disposition log. c. Morphine Sulfate 20 mg/ml, give 0.50 mL three times daily for pain or shortness of breath: * A page in the disposition log for Morphine Sulfate 20 mg/ml had directions to “take .75ml by mouth every hour as needed for pain/shortness of breath.” Every dose signed out on this page noted “0.50 mL,” was given three times a day on 07/23/25 through 07/28/25, and corresponded to the doses on the MAR for the routine morphine, 0.50mL three times daily, not 0.75 mL every hour PRN. Additionally, multiple entries on the log did not indicate am or pm. On 07/30/25 Staff 2 (LPN/Senior Health Services Director) acknowledged the wrong page was used for Resident 1’s routine Morphine Sulfate medication. d. One page in the disposition log was for “Methadone HCl 5 mg 1 tablet twice a day,” dated 05/06/25, an order that had been discontinued. The disposition log showed “1” dose was signed out twice a day through 05/26/25. The next entries on the log were on 07/11/25, 07/12/25, and 07/13/25 with a dose of “1.5” and the corresponding times lacked am or pm. Documentation in the log indicated the unused medication was destroyed on 07/14/25. In an interview with Staff 2 on 07/30/25, she acknowledged the 1.5 tablets signed out in this log on 07/11/25 through 07/13/24 were documented on the wrong page. Comparison of the medication bubble packs for methadone and liquid morphine to the disposition logs, showed the amount of medication left was reflected accurately on the logs. The need to ensure narcotic disposition logs accurately reflected the medications administered was discussed with Staff 1 (ED) and Staff 2 on 07/30/25. The staff acknowledged the findings.

Items identified as out of compliance with OAR C302 will be addressed and corrected. The facility will return to full compliance by September 8, 2025, through the following actions: 1. On 8/21/25, Resident #1’s MAR, controlled substance logs, and physician orders were reviewed, and identified concerns were addressed. The RCC or designee also reviewed controlled substance use for all residents by comparing MARs, physician orders, and controlled substance logs, with corrections made as needed. 2. The designee re-educated the RCC and ED on the regulatory requirements for accurate controlled substance tracking. Med Techs were re-educated on proper controlled substance administration procedures. 3. The RCC or designee will conduct random audits of controlled substance compliance using documentation review, observation, and/or staff interview. Audits will occur weekly for three weeks, then monthly for two months. 4. The RCC, ED, or Licensed Nurse is responsible for oversight, accuracy, and ongoing compliance related to controlled substance documentation and administration.

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 MARs were accurate and included reasons for use, medication-specific instructions, and clear parameters for PRN medications for 3 of 3 sampled residents (#s 1, 2, and 3) whose records were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 12/2024, with diagnoses including kidney disease, anxiety, and chronic obstructive pulmonary disease (COPD). Review of Resident 2’s MAR, dated 07/01/25 through 07/28/25, revealed the following: The MAR lacked reasons for use for the following medications: *Fexofenadine; *Omeprazole; *Roflumilast; *Pregabalin; *Acetaminophen; *Albuterol; *Budes/form inhaler; and *Lorazepam. On 07/30/25, the need to ensure MARs were complete and accurate, including reasons for use for all medications, was discussed with Staff 1 (ED). She acknowledged the findings. 2. Resident 3 was admitted to the facility in 04/2025 with diagnoses including hypertension. The following medications lacked reasons for use on the MAR: * Amlodipine 5mg; * Atorvastin 10mg; * Donepezil 5mg; and * Lisinopril 40mg. On 07/30/25, the need to ensure all medications on the MAR indicated clear reasons for use was discussed with Staff 1 (ED). She acknowledged the findings. 3. Resident 1 was admitted to the facility in 04/2023 with diagnoses including chronic kidney disease and spinal stenosis. Review of Resident 2’s MAR, dated 07/01/25 through 07/28/25, revealed the following: a. The MAR lacked reasons for use for the following medications: *Doxycycline Mono 100 mg; *Omeprazole 20 mg; *Methadone 5 mg; *Potassium Chloride 10 MEQ; *Zeasorb 2% powder; and *Refresh 1.4-0.6% eye drops. b. The medication record did not include specific parameters and instructions for PRN medications, including the sequential order of which to administer PRN medications with the same reasons for use for the following: * Haloperidol for nausea and/or vomiting; * Ondansetron for nausea and/or vomiting; * Docusate sodium for constipation; * Polyethylene glycol for constipation; * Cepacol ES for cough; * Guaifenesin for cough; * Morphine sulfate for moderate for pain; * Acetaminophen for pain; and * Lidocaine cream for pain. On 07/30/25, the need to ensure MARs were complete and accurate, including reasons for use of all medications and instructions for PRN medications was discussed with Staff 1 (ED) and Staff 2 (LPN/Senior Health Services Director) on 07/30/25. They acknowledged the findings.

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 written, signed physician orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer for 1 of 3 sampled residents (# 1) whose MARs and orders were reviewed. Findings include, but are not limited to: Resident 1 was admitted to the facility in 04/2023 with diagnoses including chronic kidney disease and spinal stenosis. The resident's 07/01/25 to 07/28/25 MAR and physician orders, dated 05/19/25, were reviewed. The following was identified: * Morphine Sulfate 20 mg/mL 0.75 mL every hour as needed for pain or shortness of breath was ordered with instructions to hold the medication if respirations were less than 8 breaths per minute. The MAR revealed the facility did not monitor respirations prior to administering the PRN dosage. Additionally, the MAR revealed the PRN morphine dose was discontinued on 07/10/25. The facility could not provide an order to indicate this medication had been discontinued. In an interview on 07/29/25 at 2:30 pm, Staff 2 (LPN/Senior Health Services Director) indicated an order to discontinue the PRN Morphine could not be located. On 07/30/25 at 10:13 am, Staff 2 indicated she clarified with hospice that Resident 1 should still have morphine sulfate PRN for pain and confirmed the medication was now on the MAR to be administered to Resident 1 as needed for pain. * Bisacodyl 10 mg suppository every day PRN constipation was ordered with instructions to give if no bowel movement (BM) in three days. A physician’s order included “when resident has not had a BM in 3 days, MT to give suppository, notify hospice.” The MAR indicated the facility monitored for a BM four times a day and revealed Resident 1 had not had a BM in greater than three days on three separate occasions, from 07/04/25 to 07/06/25, 07/08/25 to 07/12/25, and 07/14/25 to 07/21/25, and would have indicated the need to administer the suppository. There was no documented evidence Resident 1 had received the bisacodyl suppository from 07/01/25 to 07/28/25 or that hospice was notified. * A physician’s order was to obtain Resident 1’s weight “3X a week to monitor [his/her] edema. Notify PCP if > 180 [pounds]”. On 7/01/25 the MAR revealed Resident 1’s weight was 187 pounds. There was no documentation provided that the facility notified the physician when his/her weight was > 180 pounds. * An order for Zeasorb 2% powder to be applied to affected areas 2 times daily (for fungal skin infections) was ordered. The MAR indicated Resident 1 was self-administering this medication. On 07/29/25 Staff 2 confirmed Resident 1 no longer managed any of his/her medication, including Zeasorb, and had not been receiving the medication. On 07/30/25 Staff 8 (Med Aide) confirmed the medication was not in the facility. * A treatment order, dated 04/23/25, for oxygen 2 L/min via nasal cannula PRN shortness of breath was missing on the MAR. The need to have signed physician orders in the resident's record and to ensure physician orders were carried out as prescribed was discussed with Staff 1 (ED) and Staff 2 on 07/20/25. They acknowledged the findings.

Items identified as out of compliance with OAR C303 will be addressed and corrected. The facility will return to full compliance by September 28, 2025, through the following actions: 1. Hospice was contacted for an update regarding Resident #1. The RCC or designee reviewed the resident’s current orders and forwarded them to the physician for signature. Yes, the MAR has been updated to include the requirement to check respirations prior to administering morphine, and oxygen has been added as ordered for this resident. In addition, 90-day order reviews were recently completed for the community, returned from the physicians, and all reviews have been finalized. 2. Within SMART meeting (Clinical Meeting), the ED, RCC, Designee will review order discrepancy and medication audit report. Training completed with RCC on 8/22/2025 by RN. The designee re-educated the RCC and ED on the requirement that all physician orders must be carried out as prescribed. Med Techs were re-educated on proper use of the three-folder system to support compliance with physician orders. 3. The RCC or designee will review resident orders via SMART to ensure compliance weekly for three weeks, then monthly for two months. 4. The RCC and ED are responsible for oversight and ensuring ongoing compliance with physician orders.

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 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included reasons for use, medication-specific instructions, and clear parameters for PRN medications for 3 of 3 sampled residents (#s 1, 2, and 3) whose records were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 12/2024, with diagnoses including kidney disease, anxiety, and chronic obstructive pulmonary disease (COPD). Review of Resident 2’s MAR, dated 07/01/25 through 07/28/25, revealed the following: The MAR lacked reasons for use for the following medications: *Fexofenadine; *Omeprazole; *Roflumilast; *Pregabalin; *Acetaminophen; *Albuterol; *Budes/form inhaler; and *Lorazepam. On 07/30/25, the need to ensure MARs were complete and accurate, including reasons for use for all medications, was discussed with Staff 1 (ED). She acknowledged the findings. 2. Resident 3 was admitted to the facility in 04/2025 with diagnoses including hypertension. The following medications lacked reasons for use on the MAR: * Amlodipine 5mg; * Atorvastin 10mg; * Donepezil 5mg; and * Lisinopril 40mg. On 07/30/25, the need to ensure all medications on the MAR indicated clear reasons for use was discussed with Staff 1 (ED). She acknowledged the findings. 3. Resident 1 was admitted to the facility in 04/2023 with diagnoses including chronic kidney disease and spinal stenosis. Review of Resident 2’s MAR, dated 07/01/25 through 07/28/25, revealed the following: a. The MAR lacked reasons for use for the following medications: *Doxycycline Mono 100 mg; *Omeprazole 20 mg; *Methadone 5 mg; *Potassium Chloride 10 MEQ; *Zeasorb 2% powder; and *Refresh 1.4-0.6% eye drops. b. The medication record did not include specific parameters and instructions for PRN medications, including the sequential order of which to administer PRN medications with the same reasons for use for the following: * Haloperidol for nausea and/or vomiting; * Ondansetron for nausea and/or vomiting; * Docusate sodium for constipation; * Polyethylene glycol for constipation; * Cepacol ES for cough; * Guaifenesin for cough; * Morphine sulfate for moderate for pain; * Acetaminophen for pain; and * Lidocaine cream for pain. On 07/30/25, the need to ensure MARs were complete and accurate, including reasons for use of all medications and instructions for PRN medications was discussed with Staff 1 (ED) and Staff 2 (LPN/Senior Health Services Director) on 07/30/25. They acknowledged the findings.

Items identified as out of compliance with OAR C310 will be addressed and corrected. The facility will return to full compliance by September 28, 2025, through the following actions: 1. Indications for residents 1,2,3 medications and treatment orders audited and updated as needed. Resident #1, #2, and #3 PRN medications were reviewed to ensure resident-specific parameters and instructions were present. The RCC and designee also reviewed current PRN medications for all residents, addressing any concerns identified. 2. The designee re-educated the RCC on the requirement that all PRN medications must include resident-specific parameters and instructions. Training: Order flow process, three folder system, parameters, PRN and scheduled medication use, monitoring, notifications, controlled medications, short term health monitoring, recognizing change of condition completed with Med Tech, ED, RCC training completed 8/19/25 by RN and Operations Specialist. Current residents' medication have been audited for indications of use. Community ED, RCC, designee will review daily during SMART meeting and through the third check system for missing indications and add as needed. *Pharmacy audit scheduled for 09/02/2025. 3. The RCC or designee will review new medication orders via SMART to confirm resident-specific parameters and instructions are included. Reviews will occur weekly for three weeks, then monthly for two months. 4. The RCC and ED are responsible for oversight and ensuring ongoing compliance with PRN medication requirements.

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 interview and record review, it was determined the facility failed to ensure residents who self-administered medications had a physician's order in place for 1 of 1 sampled resident (# 2) who administered their own medications. Findings include, but are not limited to: Resident 2 was admitted to the facility in 12/2024, with diagnoses including kidney disease, anxiety, and chronic obstructive pulmonary disease (COPD). In the acuity interview on 07/28/25, Resident 2 was identified as administering his/her own medications. Review of the resident’s quarterly service plan and evaluation, both dated 07/03/25, MAR, dated 07/01/25 through 07/28/25, and physician orders revealed the following: There was no current physician order to allow self-administration of medications by Resident 2. On 07/30/25, the need to ensure all residents who self-administered medications had a current physician order in place to allow the self-administration was discussed with Staff 1 (ED). She acknowledged the findings.

Items identified as out of compliance with OAR C325 will be addressed and corrected. The facility will return to full compliance by September 28, 2025, through the following actions: 1. Resident #2’s orders were reviewed, an evaluation was completed, and applicable physician orders were obtained for self-administration of medication. 2. The RCC or designee will review all current residents for required self-administration evaluations and corresponding physician orders, addressing any concerns identified. 3. The designee re-educated the ED, RCC, and Med Techs on the requirement that a self-administration evaluation and physician order must be in place prior to self-administration. The RCC or designee will conduct audits of self-administration compliance through documentation review, observation, and/or staff and resident interviews. Audits will occur weekly for three weeks, then monthly for two months. 4. The RCC, ED, or Licensed Nurse is responsible for oversight and ensuring ongoing compliance with self-administration requirements.

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 411-054-0060 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 restraining qualities was assessed thoroughly by an RN, PT, or OT prior to use, other less restrictive alternatives evaluated prior to use of the device were documented, caregivers were instructed on the correct use of and precautions for the device, and use of the device was included in the resident's service plan, for 2 of 2 sampled residents (#s 1 and 4) who had side rails on his/her bed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 03/2023 with diagnoses including osteoarthritis. Resident 4 was observed during the survey on 07/30/25 and noted to have side rails attached to his/her bed in the up position. Review of the resident's clinical record revealed the following: * No documented evidence Resident 4 requested or approved of side rails being used and was informed of the risks and benefits of the side rails; * No documented evidence of an assessment completed by an RN, PT, or OT for the use of the side rails; * No documented evidence other less restrictive alternatives had been attempted prior to use; and * The 06/26/25 service plan lacked information related to the use of side rails, and did not include instructions to staff about the correct use of and precautions for the device. No further documentation was provided. On 07/30/25, the lack of an assessment and documentation of requirements for side rail use was discussed with Staff 1 (ED). She acknowledged the findings. 3. Resident 1 was admitted to the facility in 04/2023 with diagnoses including chronic kidney disease and spinal stenosis. During the acuity interview on 07/28/25, Resident 1 was identified as having two side rails on his/her bed. Observations of the resident and the resident's room on 07/29/25 at 2:22 pm showed no side rail on the right side of the bed and one side rail on the left side in the up position. This represented a device with restraining qualities. Additionally, the rail was loose, and Resident 1 acknowledged s/he didn’t use the rail because it was “shaky.” Review of Resident 1's record revealed there was no documented evidence the device with restraining qualities had been assessed by an RN, PT, or OT, no documentation of other less restrictive alternatives evaluated prior to use of the device, no documentation of instruction to caregivers on correct use of and precautions for the device, and no documentation of the use of the side rails in the resident's service plan. During an interview on 07/29/25 at 2:00 pm, Staff 2 (LPN/Senior Health Services Director) acknowledged no assessment had been completed for Resident 1's side rail. She checked on the side rail and determined it was too loose to fix and removed the rail with the resident’s permission. A new hospital bed was ordered with no rails as Staff 2 did not feel the resident was currently safe to use the side rail but could be assessed by the facility RN or hospice at a later date. On 07/29/25 at 3:30 pm the surveyor observed the side rail had been removed. The need to ensure the use of a supportive device with restraining qualities included documentation of all required elements and was included in the resident's service plan was discussed with Staff 1 (ED) and Staff 2 on 07/30/25. They acknowledged the findings.

Items identified as out of compliance with OAR C340 will be addressed and corrected. The facility will return to full compliance by September 28, 2025, through the following actions: 1. Resident #1 and Resident #4’s use of side rails was reviewed by the RN, and identified concerns were addressed. RN completed enabler device assessments by going to resident apartments to identify supportive devices. RN updating service plans to reflect supportive devices and monitoring needs. 2. The designee re-educated the ED and RCC on the requirements for the use of restraints and supportive devices, including: o Completion of an assessment prior to use o Evaluation and documentation of less restrictive alternatives o Instructions for caregivers on proper use and precautions related to the device. Yes, all supportive device evaluations for residents with side rails have been completed by a Registered Nurse, and documentation is included in the resident service plans and will continue to be evaluated on a quarterly basis in compliance with the rule. 3. The RCC or designee will conduct random audits of restraints and supportive devices through documentation review, observation, and/or staff interviews. Audits will occur weekly for three weeks, then monthly for two months. 4. The RCC and ED are responsible for oversight and ensuring ongoing compliance with restraint and supportive device requirements.

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 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the environment was maintained in clean and good repair. Findings include, but are not limited to: The facility was toured on 07/28/25 at 11:10 am. The following deficiencies were identified: * Scuffs and scrapes on wood baseboards near rooms 101, 102, 111, 112, maintenance room, activities room, rest room, and laundry room; * Scrapes and gouges on wood doors/jambs of rooms 111, 112, 121, 122, 123, 124, and 125; * Wood handrails in multiple areas had chipped paint and scrapes; * Stains on carpet near room 114; * Chips and scratches on wood chair legs in dining room; and * Gouges and damage to paint and wood of pillars near dining room. On 07/30/25, the need to ensure the facility was kept clean and in good repair was discussed with Staff 1 (ED). She acknowledged the findings.

Items referenced to be out of compliance with OAR (C 613) will be addressed, corrected and facility will be in compliance. 1. Scuff and scrapes on wood baseboards near rooms 101, 102, 111, 112, maintenance room, activities room, rest room and laundry room have been repaired. Scrapes and gouges on wood doors/jambs of rooms 111, 112, 121, 122, 123, 124 and 125 have been addressed. Chipped paint and scrapes on wood handrails have been addressed. Stains on carpet near room 114 have been cleaned. Chips and scratches on wood chair legs in dining room have been addressed. Gouges and damage to paint and wood of pillars near dining room have been addressed. ED walked community for cleanliness and good repair, addressing concerns identified. 2. Designee re-educated ED on the requirement to keep the community well maintained and in good repair. ED of Designee retrained staff on reporting maintenance concerns. 3. ED or Designee will walk community for maintenance concerns and cleanliness weekly x 3 weeks monthly x 2 months or until compliance has been achieved. 4. 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 provide security and to alert staff when residents exited the building. Findings include, but are not limited to: On 07/28/25 at 11:10 am, a tour of the facility was conducted. The following was identified: The exit doors from the ALF to the outside courtyard area failed to have a working alarm or other acceptable system to alert staff when residents left the building. In an interview on 07/29/25, Staff 1 (ED) confirmed there was no door alarm or system to alert staff when the doors to the outdoor courtyard were opened. On 07/30/25, the lack of alarms on exit doors was discussed with Staff 1. She 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 9/28/25 by completing the following: 1. The exit door from the ALF to the outside courtyard area was equipped with an alarming device. 2. Designee re-educated the ED on the requirement that exit doors are equipped with an alarming device. 4. ED or Designee will audit exit door for alarm device compliance weekly x 3 weeks then monthly x 2 or until compliance has been achieved. 4. 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: