Elena's Manor

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.

Based on interview and record review, it was determined the facility failed to report a physical injury of unknown cause to the local Department office as suspected abuse unless an immediate facility investigation reasonably concluded and documented the physical injury was not the result of abuse, and failed to immediately notify the local Department office of any incident of suspected abuse, investigate all reports of abuse or suspected abuse, and document the investigation as required for 2 of 4 sampled residents (#s 1 and 5) with an injury of unknown cause and elopement. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 10/2024 with diagnoses including Lewy Body Dementia. During the acuity interview on 02/17/26, Staff 3 (ED/Human Resources), Staff 5 (RN), and Staff 6 (Lead MT) reported Resident 5 had recently eloped from the facility and was outside in front of the building for approximately ten minutes before an unsampled resident’s visitor noticed him/her and brought him/her back into the building. On 02/17/26 at 2:15 pm, the surveyor met with Staff 1 and 2 and requested documentation of this incident. They stated the incident occurred on 01/16/26. They were not able to provide any documentation about the incident. An elopement from an endorsed memory care community, which is intended to be locked and secure, represents an incident of suspected abuse that must be immediately reported to the local Department office and investigated. The facility failed to report the incident to the local Department office and failed to document an investigation that included: * Time, date, place, and individuals present; * Description of the event as reported; * Response of staff at the time of the event; * Follow-up action; and * Administrator’s review. The incident was reviewed with Staff 3, Staff 5, and Staff 4 (Assistant ED/Marketing Director) on 02/18/26 at 2:10 pm. They acknowledged the facility failed to report the incident to the local office and failed to document an investigation as required. The surveyor directed the facility to report the incident to the local Department office as suspected abuse. Confirmation the facility reported as directed was received on 02/19/26 at 8:35 am. 2. Resident 1 was admitted into the facility in 10/2025 with diagnoses including severe dementia. The resident’s 11/19/25 to 02/16/26 clinical record was reviewed. The following was identified: Staff documented on 01/05/26 a two-inch by three-inch “dark purple” bruise to Resident 1’s “lower left calf” was discovered while assisting the resident to the bathroom. When asking Resident 1 about how s/he obtained the bruise, staff documented, “Resident was not able to recall.” An incident report, dated 01/05/26, was reviewed. There was no documented evidence the facility was able to reasonably conclude that the physical injury was not the result of abuse. On 02/18/26, Staff 5 (RN) reported the facility was not able to determine how the bruise occurred, and the local Department office had not been notified of the injury of unknown cause. Survey requested the facility report the incident, and confirmation that the facility reported the injury of unknown cause to the local Department office was received on 02/19/26 at 11:29 am. The need to ensure the local Department office was notified if the facility’s investigation of an injury of unknown cause could not reasonably conclude and document that the physical injury was not the result of abuse was discussed with Staff 1 (Co-owner), Staff 3 (ED/Human Resources), Staff 5, and Staff 6 (Lead MT) on 02/19/26 at 3:53 pm. They acknowledged the findings.

Upon identification of the deficiency related to OAR 411-054-0028 (1–3) Reporting and Investigating Abuse – Other Action, the facility immediately reviewed the incident involving the identified resident(s) and ensured appropriate reporting to the required authorities in accordance with mandatory reporting requirements. The resident(s) involved were assessed to ensure their safety and well-being, and care plans were reviewed and updated as needed. Staff involved in the incident received immediate re-education regarding abuse recognition, mandatory reporting requirements, and investigation procedures. To determine if other residents may have been affected, the Executive Director conducted a review of recent incident reports, abuse logs, and investigation documentation, and staff interviews were completed as appropriate. No additional concerns were identified, and any potential reportable events would be reported immediately according to rule. To prevent recurrence, the facility provided mandatory training for all staff on abuse prevention, recognition, and reporting requirements, and reinforced facility policy outlining the steps for timely reporting and documentation. A standardized abuse reporting and investigation process has been implemented, and the Executive Director or designee will review all incident reports daily to ensure reportable events are identified promptly. Ongoing compliance will be monitored through weekly audits of incident reports and abuse logs for 90 days, after which monitoring will transition to routine quality assurance reviews. Any IMMEDIATLEY Accepted Yes No 2. How will the system be corrected so this violation will not happen again? Accepted Yes No 3. How often will the area needing correction be evaluated? Accepted Yes No 4. Who will be responsible to see that the corrections are completed/monitored? Accepted Yes No Page 2 | 27 identified concerns will result in immediate corrective action and staff re-education.

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.

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

Based on interview, and record review, it was determined the facility failed to ensure the initial evaluation contained all required elements for 1 of 1 sampled resident (#4) whose initial evaluation was reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 02/2026 with diagnoses including dementia with behaviors. The resident’s move-in evaluation was reviewed, and the following elements were not addressed: * Name, preferred pronouns, and gender identity; * Customary routines for eating and bathing; * Cultural preferences and traditions; * Cognition: memory and decision-making abilities; * How the person copes with change or challenging situations; * Vision ability; * ADLs, including toileting and transfer ability; and * Dental status. The need to ensure all elements were addressed in the initial evaluation was reviewed with Staff 1 (Co-owner), Staff 3 (ED/Human Resources), Staff 5 (RN), and Staff 6 (Lead MT) on 02/19/26 at 3:20 pm. They acknowledged the information that was lacking.

Upon identification of the deficiency related to OAR 411-054-0034 (1–6) Resident Move-in and Evaluation, The facility immediately reviewed the resident evaluation for the identified resident(s) to ensure that required assessments and documentation were completed and accurately reflected the resident’s current needs. Any missing or incomplete information was updated in the resident record, and care plans were reviewed to ensure services and supports were appropriate. The Executive Director and nursing staff conducted a review of current resident files to determine if other residents may have been affected by incomplete or untimely evaluations. Any discrepancies identified were corrected promptly to ensure compliance with evaluation requirements. To prevent recurrence, the facility provided re-education to nursing and administrative staff responsible for admissions and evaluations regarding the required components and timelines for completing resident move-in evaluations in accordance with OAR 411-054-0034. The facility also implemented a standardized admission and evaluation checklist to ensure all required documentation is completed prior to or at move-in and reviewed within required timeframes. The Executive Director or designee will monitor compliance by auditing new admission files weekly for 90 days to verify that resident evaluations are completed accurately and timely. After 90 days, audits will transition to routine quality assurance monitoring. Any variances identified will result in immediate correction and additional staff education.

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

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.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction to staff regarding the delivery of service, and/or were implemented for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 admitted to the facility in 10/2025 with diagnoses including severe dementia. The resident’s service plan, dated 02/16/26, and temporary service plans, dated 11/12/25 through 02/07/26, were reviewed, and interviews were conducted with staff. The following was not reflective of Resident 1’s needs or lacked clear direction to staff: * Current incontinent status and brief use; * How the resident participated in dressing; * The use of a shower bench; * Person-centered behavioral interventions; and * Current elopement status. On 02/18/26 at 2:06 pm, Staff 11 (MT/CG) confirmed the resident’s incontinent status and brief use. He addressed how Resident 1 assisted in the dressing process and the use of a shower bench for safety. Staff 11 was aware of person-centered behavioral interventions and confirmed they were not reflected on the resident’s service plan. The need to ensure service plans were reflective and provided clear direction to staff was discussed with Staff 1 (Co-owner), Staff 3 (ED/Human Resources), Staff 5 and Staff 6 (Lead MT) on 02/19/26 at 3:53 pm. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 06/2025 with diagnoses including dementia. The resident’s clinical record, dated 11/15/25 through 02/17/26, was reviewed, observations were made, and interviews were conducted with staff. The 02/16/26 service plan and 11/15/25 to 02/16/26 temporary service plans (TSPs) were not reflective of the resident’s current status, lacked clear instructions for staff, or were not implemented in the following areas: * Swallowing precautions; * Level of assistance for personal hygiene; * Assistance with activities; and * Fall precautions. During the acuity interview on 02/17/26, the resident was noted to have difficulty swallowing which resulted in the resident being sent to the hospital and had a history of falls. The service plan indicated the resident’s wheelchair should be kept out of the resident’s reach while in bed to prevent falls. The 02/09/26 TSP indicated the resident should be kept upright for 30 minutes following meals. During an observation on 02/18/26, staff assisted the resident to lie down in bed immediately following lunch. On 02/18/26 and 02/19/26, the wheelchair was placed next to the bed, allowing the resident to reach it while in bed. The need to ensure service plans were reflective of the resident’s status, provided clear direction to staff regarding the delivery of services, and were implemented was reviewed with Staff 1 (Co-owner), Staff 3 (ED/Human Resources) and Staff 5 (RN) on 02/19/26 at 11:52 am. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 06/2025 with diagnoses including vascular dementia and depression. The resident’s clinical record from 11/18/25 to 02/16/26 was reviewed, observations were made, and interviews were conducted with staff. The following was identified: The service plan dated 02/16/26 was not reflective or lacked a description of how staff should provide the care and services in the following areas: * Toileting; * Transfers; * Pain; and * Speech. During an observation of personal care on 02/19/26 at 1:10pm, staff escorted the resident to the toilet. Staff 7 (CG) and Staff 9 (CG) confirmed they always offered to escort the resident to the toilet. The service plan did not include instructions for staff to escort the resident to the toilet. During the survey, staff were observed to have the resident use a walker for stability during transfers. In an interview on 02/19/26 at 1:20 pm, Staff 7 and Staff 9 confirmed they always used the walker during transfers. The service plan did not include instructions for staff to utilize the walker. The service plan indicated the resident’s speech was clear and understandable. Multiple interviews with the resident and observations during the survey indicated the resident was sometimes difficult to understand. The need to ensure service plan was reflective of the resident’s status and provided clear direction to staff regarding the delivery of services was reviewed with Staff 1 (Co-owner), Staff 3 (ED/Human Resources), Staff 5 (RN), and Staff 6 (Lead MT) on 02/19/26 at 3:45 pm. They acknowledged the findings.

Upon identification of the deficiency related to OAR 411-054-0036 (1–4) Service Plan: General, the facility immediately reviewed the service plan for the identified resident(s) to ensure that the plan accurately reflected the resident’s current needs, preferences, and required services. Any missing or incomplete information was corrected, and the service plan was updated to ensure it provided clear direction to staff regarding the care and support required. The resident’s record and care plan were reviewed with relevant staff to ensure understanding and consistent implementation of the updated service plan. To determine if other residents may have been affected, the Executive Director and nursing staff conducted a review of current resident service plans to verify that plans were completed, current, and reflective of each resident’s assessed needs. Any discrepancies identified during the review were corrected promptly. To prevent recurrence, the facility provided re-education to staff responsible for completing and updating service plans regarding required components, documentation standards, and timelines in accordance with OAR 411-054-0036. The facility also implemented a standardized service plan review checklist to ensure all required elements are included and updated as residents’ needs change. Ongoing compliance will be monitored by the Executive Director or designee through weekly audits of resident service plans for 90 days to verify accuracy, completeness, and timeliness. After 90 days, monitoring will transition to routine quality assurance reviews. Any identified concerns will result in immediate correction and additional staff training.

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.

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.

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 2 of 3 sampled residents (#s 2 and 3) whose records were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 06/2025 with diagnoses including depression, insomnia, and dementia. Resident 2's 11/06/25 and 02/16/26 physician’s orders and 02/01/26 through 02/17/26 MAR/TARs were reviewed. The following prescribed medications were not transcribed, or were incorrectly transcribed, on the MAR: * Quetiapine fumirate, for agitation; * Trazadone, for sleep; and * Hyoscyamine, for secretions. The need to ensure all medications were carried out as prescribed was discussed with Staff 1 (Co-owner), Staff 3 (ED/Human Resources) and Staff 5 (RN) on 02/19/26 at 11:52 am. They acknowledged the findings. On 02/19/26 at 12:58 pm, Staff 5 confirmed the orders had not been carried out as prescribed. 2. Resident 3 was admitted to the facility in 06/2025 with diagnoses including vascular dementia, depression, hypertension and hypoxemia. On 02/19/26 at 11:00 am, the resident's 02/01/26 through 02/16/26 and current signed physician orders were reviewed. Resident 3 was prescribed metoprolol succinate 50 mg, 1 tablet every day, for hypertension with instructions to hold for systolic blood pressure (SBP) less than 100 and/or pulse less than 55. The MAR indicated the resident’s SBP was less than 100 on 02/09/26 and the resident’s pulse was less than 55 on 02/01/26, 02/02/26, 02/07/26 and 02/10/26, but the medication was administered on each of these days. The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (Co-owner), Staff 3 (ED/Human Resources), Staff 5 (RN), and Staff 6 (Lead MT) on 02/19/26 at 3:40 pm. During this interview, Staff 5 requested an opportunity to review the MAR. On 02/19/26 at 5:30 pm, Staff 5 reviewed Resident 3’s electronic MAR with the surveyor and acknowledged the metoprolol was not held per physician’s orders.

Upon identification of the deficiency related to OAR 411-054-0055 (1)(f–h) Systems: Treatment Orders, the facility immediately reviewed the treatment orders for the identified resident(s) to ensure all physician or licensed practitioner orders were accurately documented, current, and properly implemented. Any missing, unclear, or outdated treatment orders were clarified with the appropriate licensed practitioner and updated in the resident record to ensure staff had clear direction for implementation. The resident’s care documentation and service plan were reviewed with staff to ensure treatments were being completed as ordered. To determine if other residents may have been affected, the Executive Director and nursing staff conducted a review of resident records to verify that all treatment orders were present, current, and consistently followed. Any discrepancies identified during the review were corrected promptly. To prevent recurrence, the facility provided re-education to staff responsible for receiving, documenting, and implementing treatment orders regarding proper documentation procedures, verification of practitioner orders, and ensuring treatments are completed as directed. The facility also implemented a standardized process for reviewing and verifying treatment orders upon receipt and during routine chart reviews. Ongoing compliance will be monitored by the Executive Director or designee through weekly audits of resident records and treatment orders for 90 days to ensure accuracy, completeness, and implementation of orders as required. After 90 days, monitoring will transition to routine quality assurance reviews. Any identified concerns will result in immediate corrective action and additional staff education

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.

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.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident-specific parameters and instructions for PRN medications for 1 of 1 sampled resident (#3) who was prescribed multiple PRN medications for shortness of breath. Findings include, but are not limited to: Resident 3 was admitted to the facility in 06/2025 with diagnoses including vascular dementia, depression, hypertension and hypoxemia. Resident 3's MAR from 02/01/26 through 02/16/26 was reviewed during the survey, and the following was identified: The resident was prescribed the following four PRN medications for shortness of breath/respiratory distress: * Albuterol inhaler; * Ipratropium and albuterol nebulizer; * Hydromorphone; and * Oxygen (administered via concentrator or portable tank). The MAR lacked resident-specific parameters and instructions for these PRN medications, including which intervention to attempt first and what to do if ineffective. The need for resident-specific parameters and clear instructions for PRN medications was discussed with Staff 1 (Co-owner), Staff 3 (ED/Human Resources), Staff 5 (RN), and Staff 6 (Lead MT) on 02/19/26 at 3:40pm. They acknowledged the findings.

Upon identification of the deficiency related to OAR 411-054-0055 (1)(f–h) Systems: Treatment Orders, the facility immediately reviewed the treatment orders for the identified resident(s) to ensure all physician or licensed practitioner orders were accurately documented, current, and properly implemented. Any missing, unclear, or outdated treatment orders were clarified with the appropriate licensed practitioner and updated in the resident record to ensure staff had clear direction for implementation. The resident’s care documentation and service plan were reviewed with staff to ensure treatments were being completed as ordered. To determine if other residents may have been affected, the Executive Director and nursing staff conducted a review of resident records to verify that all treatment orders were present, current, and consistently followed. Any discrepancies identified during the review were corrected promptly. To prevent recurrence, the facility provided re-education to staff responsible for receiving, documenting, and implementing treatment orders regarding proper documentation procedures, verification of practitioner orders, and ensuring treatments are completed as directed. The facility also implemented a standardized process for reviewing and verifying treatment orders upon receipt and during routine chart reviews. Ongoing compliance will be monitored by the Executive Director or designee through weekly audits of resident records and treatment orders for 90 days to ensure accuracy, completeness, and implementation of orders as required. After 90 days, monitoring will transition to routine quality assurance reviews. Any identified concerns will result in immediate corrective action and additional staff education Addendum on 04/01/26, submitted by Ericka Forman : Inaccurate or unclear documentation on the MAR, including lack of defined parameters for PRN medications (e.g., sequencing when multiple PRNs are ordered for the same condition). 2. Corrective Actions Taken for Affected Residents All current physician orders were reviewed for accuracy and completeness. PRN medication orders were clarified with prescribing providers to ensure: Clear indications for use, Defined administration parameters Explicit sequencing instructions when multiple PRNs exist for the same symptoms. MARs were immediately updated to reflect clarified orders. Staff re-educated on any updated or corrected orders prior to next medication pass. 3. Systemic Changes to Prevent Recurrence Physician Order Process Improvements: All new and revised orders will be reviewed by a licensed nurse prior to transcription onto the MAR. Any PRN order lacking specificity will be clarified with the provider before implementation. MAR Accuracy Protocol: Standardized process implemented requiring: Documentation of indication, Clear frequency and timing, Step-by-step PRN hierarchy (e.g., “Administer Medication A first; if ineffective after X time, administer Medication B”). PRN Medication Guidelines: A facility-wide guideline for PRN medications has been developed and implemented. Includes required elements: Symptom identification First-line vs. second-line medication use. Documentation of effectiveness 4. Staff Education - All medication staff (RNs, LPNs, and caregivers involved in medication administration) received training on: Following physician orders precisely, Proper MAR documentation, PRN medication protocols and sequencing, New hires will receive this training during orientation. Competency validation completed post-training. 5. Monitoring and Quality Assurance - RN Oversight: The RN will conduct: Weekly scheduled audits of MARs and physician orders for 4 weeks. Random audits thereafter on an ongoing basis (minimum monthly). Audit Focus Areas: Accuracy of transcription from physician order to MAR Presence of clear PRN parameters and sequencing Documentation of medication effectiveness. Corrective Action: Any discrepancies identified will be corrected immediately. Staff involved will receive re-education and, if necessary, progressive discipline per policy. QA Review: Audit findings will be reviewed in Quality Assurance/Performance Improvement (QAPI) meetings. Trends will be tracked and addressed. 6. Completion Date Full compliance expected by: April 10,2026 7. Responsible Party Administrator / RN Designee 1. What happened? The facility failed to consistently ensure physician orders were followed as prescribed, specifically related to PRN medications lacking clear administration parameters and sequencing when multiple PRNs were ordered for the same symptoms. 2. How was the problem corrected for affected residents? All current physician orders were reviewed. PRN orders were clarified with providers to include: Indications for use. Frequency and timing. Clear sequencing when multiple PRNs are ordered MARs were updated immediately to reflect clarified orders. Staff were re-educated prior to next medication administration. 3. How will the system be corrected? All new and revised physician orders are reviewed by a licensed nurse prior to MAR transcription. PRN medications must include clear parameters before implementation. A standardized PRN protocol has been implemented defining first-line and alternative interventions. 4. How will the facility monitor to ensure compliance? RN will conduct: Weekly scheduled and random audits

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.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman.

Based on observation, interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) accurately captured the care time and care elements that staff were providing to each resident as outlined in each individual service plan for 3 of 3 sampled residents (#s 1, 2 and 3) whose ABST data was reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 10/2025 with diagnoses including severe dementia. The service plan, dated 02/16/26, temporary service plans, charting notes, and the resident's corresponding ABST evaluation were reviewed. Resident 1 was observed, and interviews were conducted with staff. The resident's care time and care elements were not reflective in the following areas: * Monitoring physical conditions or symptoms; * Providing treatments; * Bowel and bladder management; and * Supervising, cueing, or supporting while eating. The need to ensure the facility ABST accurately captured care time and care elements that staff were providing was discussed with Staff 1 (Co-owner), Staff 3 (ED/Human Resources), Staff 5 (RN) and Staff 6 (Lead MT) on 02/19/26 at 3:53 pm. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 06/2025 with diagnoses including dementia. During the acuity interview on 02/17/26, the resident was identified as having a hospital stay and experienced a significant change of condition upon returning to the facility. During the survey, the resident was observed to be dependent on staff for all ADL care. The 02/16/26 service plan, temporary service plans, charting notes, and the resident's corresponding ABST evaluation were reviewed. Resident 2 was observed, and interviews were conducted with staff. The resident's care time and care elements were not reflective in the following areas: * Monitoring physical conditions or symptoms; * Assisting with leisure activities; and *Ambulation, escorting to and from meals or activities. The need to ensure the facility ABST accurately captured care time and care elements that staff were providing was discussed with Staff 1 (Co-owner), Staff 3 (ED/Human Resources), and Staff 5 (RN) on 02/19/26 at 11:52 am. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 06/2025 with diagnoses including vascular dementia. The 02/16/26 service plan, temporary service plans, charting notes, and the resident's corresponding ABST evaluation were reviewed. Resident 3 was observed, and interviews were conducted with staff. The resident's care time and care elements were not reflective in the following areas: * Monitoring physical conditions or symptoms; * Assisting with leisure activities; * Monitoring behavioral conditions or symptoms; and * Ensuring non-drug interventions for behaviors. The need to ensure the facility ABST accurately captured care time and care elements that staff were providing was discussed with Staff 1 (Co-owner), Staff 3 (ED/Human Resources), Staff 5 (RN), and Staff 6 (Lead MT) on 02/19/26 at 3:45 pm. They acknowledged the findings.

Upon identification of deficiency the administrator and RN immediatley conducted a full reassessment of all urrent residents ABST evaluations to ensure accurate capture of providing non drug intervwentions, monitoring physical conditions and symptoms, assisting and leisure activities, cueing aor redirecting due to cognitive impaired, providing non drug interventions for pain amanagement, supervising, cueing, or supporting while eating, assissting with ambulation, escorting to and from meals or activities, To prevent recurrence, the facility provided re-education to all staff responsible for completing and updating the ABST and staffing plan, including proper documentation, timeliness of updates, and ensuring staffing assignments match resident care needs. The facility also implemented a standardized procedure for regular review and updating of the ABST and staffing plan, ensuring adjustments are made whenever resident needs change. Ongoing compliance will be monitored by the Executive Director or designee through weekly audits of the ABST and staffing plan for 90 days to verify accuracy and alignment with resident acuity. After 90 days, monitoring will transition to routine quality assurance review through the facility’s QAPI program. Any variances identified will result in immediate correction and additional staff training weekly ABST auditis will be completed by the RN and Administrator

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman.

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.

Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) evaluation was updated whenever there was a significant change of condition and no less than quarterly, at the same time the resident’s service plan was updated, for 4 of 4 sampled residents (#s 1, 2, 3, and 6) whose ABST data was reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 10/2025 with diagnoses including severe dementia. The resident’s quarterly service plan was updated on 02/16/26 but the resident’s ABST evaluation was last updated on 01/19/26. Resident 1’s ABST evaluation was not updated at the same time as his/her service plan. The need to ensure residents’ ABST evaluation was updated at the same time as the service plan was discussed with Staff 1 (Co-owner), Staff 3 (ED/Human Resources), Staff 5 (RN), and Staff 6 (Lead MT) on 02/19/26. They acknowledged the findings. 2. Resident 6 was admitted to the facility in 06/2025 with diagnoses including dementia. The resident’s quarterly service plan was updated on 02/16/26 but the resident’s ABST evaluation was last updated on 01/19/26. Resident 6’s ABST evaluation was not updated at the same time as his/her service plan. The need to ensure residents’ ABST evaluation was updated at the same time as the service plan was discussed with Staff 1 (Co-owner), Staff 3 (ED/Human Resources), Staff 5 (RN) and Staff 6 (Lead MT) on 02/19/26. They acknowledged the findings. 3. Resident 2 was admitted to the facility in 06/2025 with diagnoses including dementia. During the acuity interview, the resident was identified as having returned to the facility the previous week and having experienced a significant change in condition. The resident’s quarterly and significant change of condition evaluation and service plan were updated on 02/16/26. The resident’s ABST evaluation was last updated on 01/19/26. The resident's ABST evaluation was not updated following a significant change of condition. The need to ensure residents’ ABST evaluations were updated following a significant change in condition was discussed with Staff 1 (Co-owner), Staff 3 (ED/Human Resources), and Staff 5 (RN) on 02/19/26 at 11:52 am. They acknowledged the findings. 4. Resident 3 was admitted to the facility in 06/2025 with diagnoses including vascular dementia. The resident’s quarterly service plan was updated on 02/16/26, but the resident’s ABST evaluation was last updated on 01/19/26. Resident 3’s ABST evaluation was not updated at the same time as his/her service plan. The need to ensure residents’ ABST evaluations were updated at the same time as the service plan was discussed with Staff 1 (Co-owner), Staff 3 (ED/Human Resources), Staff 5 (RN), and Staff 6 (Lead MT) on 02/19/26 at 3:45 pm. They acknowledged the findings.

Upon identification of the deficiency related to OAR 411-054-0037 (4–6) Acuity Based Staffing Tool – Updates and Staffing Plan, the facility immediately reviewed the staffing plan and Acuity Based Staffing Tool (ABST) to ensure that it accurately reflected resident needs and was updated according to current resident acuity. Any discrepancies or outdated information were corrected, and the staffing assignments were adjusted to ensure adequate coverage based on resident care requirements. The Executive Director and nursing leadership reviewed all resident acuity assessments to determine if other residents may have been affected by incomplete or outdated staffing data, and any necessary updates were completed promptly. To prevent recurrence, the facility provided re-education to all staff responsible for completing and updating the ABST and staffing plan, including proper documentation, timeliness of updates, and ensuring staffing assignments match resident care needs. The facility also implemented a standardized procedure for regular review and updating of the ABST and staffing plan, ensuring adjustments are made whenever resident needs change. Ongoing compliance will be monitored by the Executive Director or designee through weekly audits of the ABST and staffing plan for 90 days to verify accuracy and alignment with resident acuity. After 90 days, monitoring will transition to routine quality assurance review through the facility’s QAPI program. Any variances identified will result in immediate correction and additional staff training

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.

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.

Based on interview and record review, it was determined the facility failed to conduct fire drills at different times of the day, evening, and night shifts, provide fire and life safety instruction to staff on alternate months, and address problems encountered relating to residents who resisted or failed to participate in the drills. Findings include, but are not limited to: Fire drill and staff training records were reviewed on 02/18/26. The following was identified: a. The facility provided fire drill records for the last six months, from 08/2025 through 02/2026. A fire drill was conducted in five of the six months. Four fire drills were conducted on swing shift (2:00 pm to 10:00 pm) and one fire drill was conducted on night shift (10:00 pm to 6:00 am). No fire drills were conducted on day shift (6:00 am to 2:00 pm). The facility failed to conduct fire drills at different times of the day, evening, and night shifts as required. b. In an interview on 02/19/26 at 12:33 pm, Staff 3 (ED/Human Resources) explained fire and life safety instruction was provided to staff during all-staff meetings. Review of the staff meeting records indicated instruction on fire drill procedures was presented on 05/22/25 and 11/12/25. The facility failed to provide fire and life safety instruction to staff on alternate months. c. Records for fire drills conducted on 09/29/25, 11/12/25, and 01/21/26 noted that between three and 12 residents did not participate in the fire drills for various reasons. The facility failed to address strategies for improving those residents’ participation in future fire drills. The need to ensure the facility conducted fire drills at different times of the day, evening, and night shifts, provided fire and life safety instruction to staff on alternate months, and addressed problems encountered relating to residents who resisted or failed to participate in the drills was reviewed with Staff 3 on 02/19/26 at 12:33 pm. She acknowledged the findings.

Upon identification of the deficiency related to OAR 411-054-0090 (1–2) Fire and Life Safety: Safety, The facility immediately conducted a review of the identified fire and life safety concern and ensured corrective action was taken to eliminate any immediate hazards. Safety checks were performed to verify that fire exits, alarms, sprinkler systems, extinguishers, and other life safety equipment were in proper working order, and any deficiencies were corrected promptly. The Executive Director and maintenance staff conducted a facility-wide review to determine if other areas or systems may have been affected, and all issues identified during this review were addressed to ensure resident safety. During each fire drill, staff will now complete forms that mark which residents did not participate, and corrective action will be taken to ensure those residents receive individualized support or retraining as needed. In addition, the facility will conduct safety training for all staff every other month during all-staff meetings, in addition to the planned fire drills, which will occur at random times and on random shifts to reinforce preparedness. Staff have also received re-education on fire and life safety policies, including proper use of safety equipment, emergency procedures, and routine safety checks. A standardized fire and life safety inspection checklist has been implemented to ensure ongoing compliance with all safety requirements. Ongoing monitoring will be conducted by the Executive Director or designee through weekly safety audits for 90 days, with any identified concerns corrected immediately and additional staff education provided as needed.

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.

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF 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) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF 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 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF 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.

Based on observation and interview, it was determined the facility failed to ensure exterior pathways located in the facility’s secured courtyards were maintained in good repair, the grounds were free of litter and refuse. and ensure there was locked storage for all poisons, chemicals, rodenticides, and other toxic materials. Findings include but are not limited to: The exterior of the facility was toured on 02/17/26. a. The following was identified in the secured courtyards located on the East and West Wings: * There were exterior pathways that had drop-offs in multiple areas, which created a potential tripping and fall hazard for residents; * There was refuse in each courtyard, including wipes, gloves, deflated balloons, cigarette butts, leaves, and weeds; * Cleaning equipment, and tools were stored in two of the three courtyards; and * An outside mat located in the secured courtyard across the hall from Unit 201 was not flush to the concrete patio, which created a potential tripping and fall hazard for residents. b. Chemicals were accessible to residents in the following unlocked areas: * The East Wing laundry room; * A restroom located across the hall from Unit 108; * The buffet located in the large dining room; * A storage room on the Open Wing; and * A cabinet located in the beauty salon. The areas where unsecured chemicals were identified was toured with Staff 3 (ED/Human Resources) and Staff 6 (Lead MT) on 02/17/26 at approximately 1:45 pm. Staff 3 and 6 ensured all chemicals were in locked storage during the tour. A tour of the exterior environment was completed with Staff 2 (Co-owner), Staff 3, and Staff 4 (Assistant ED) on 02/18/26 at 11:04 am. They acknowledged the potential tripping hazards and the presence of litter and refuse. The rooms identified as storage for the chemicals had coded locks observed during the tour on 02/18/26.

Upon identification of the deficiency related to OAR 411-054-0200 (3) General Building Exterior, The facility immediately conducted a review of the building exterior, including walkways, handrails, lighting, entrances, and other accessible areas, and addressed any immediate safety hazards to ensure resident, staff, and visitor safety. Maintenance staff corrected identified issues promptly by cleaning debris, repairing or removing broken lights, and ensuring that dirt and ground surfaces are level with the edges of sidewalks. The Executive Director and maintenance team conducted a facility-wide inspection to determine if other areas of the exterior were affected and completed all necessary corrections. To prevent recurrence, staff were re-educated on routine exterior safety inspections, hazard reporting procedures, and the importance of ongoing preventive maintenance. A standardized exterior inspection checklist has been implemented, with inspections conducted weekly by the Executive Director or designee. Any hazards identified during inspections will be corrected immediately by maintenance staff, and staff will be informed of findings during team meetings. Ongoing compliance will be monitored through weekly audits for 90 days, after which monitoring will transition to routine quality assurance review

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF 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) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF 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 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF 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.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (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 the 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. A RCF 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 will be kept clean and in good repair.

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: The facility's environment was toured on 02/17/26, and the following was observed: 1. East Wing: * There was black and brown debris in the ceiling light fixtures; * Multiple doors and door frames were scuffed with paint chipping off, including resident unit doors, doors leading inside staff use areas, and doors leading into the wing; * A transition strip was missing in Unit 101 and 106; * Every other light fixture was not able to turn on in the common use area and down the hallway; * The seating located in front of the common use television had torn and peeling upholstery; * The baseboards located between Unit 104 and the courtyard’s doors had spills and drips; * There was splintering wood on the double doors located across from Unit 101 and a bathroom/shower room door located across Unit 106 and 107; * Both cupboards in the shower rooms had handles in disrepair, rusted locking mechanisms, and there was exposed wood which deemed them to be uncleanable surfaces; * The ceiling and ceiling vent in the bathroom/shower room across from Unit 108 had dust accumulation and the vent was coming away from the ceiling; * The “Sprinkler Control” door was unlocked, and there were multiple tripping hazards identified inside the area; and * The door leading out to the secured courtyard was unlocked to get outside, but it locked from the outside and prevented re-entry into the wing. 2. Open Wing: * There was black and brown debris in the ceiling light fixtures; * Multiple doors and door frames were scuffed with paint chipping off, including resident unit doors and doors leading inside staff use areas; * Transition strips were missing in the hallway and the beauty shop; * The buffet had knobs in disrepair and chipped varnish; and * The thermostat casing (labeled “#9”) was in disrepair. 3. West Wing: * Multiple doors and door frames were scuffed with paint chipping off, including resident unit doors, doors leading inside staff use areas and doors leading into the wing’s hall; * There were loose tacks located in a drawer underneath the television, in a common area; * The double doors leading out to the secured courtyard were easily opened to go outside, but were difficult to open to re-enter the wing; * There were multiple paint chips and scrapes in the two common use areas that residents were observed watching television and doing activities in; and * The linoleum was missing and peeling away from the backsplash located to the left of the sink where water and snacks were stored. A tour of the environment was completed with Staff 2 (Co-owner), Staff 3 (ED/Human Resources) and Staff 4 (Assistant ED) on 02/18/26 at 11:04 am. They acknowledged the areas in need of cleaning and repair.

Upon identification of the deficiency related to OAR 411-054-0200 (4)(d–i) Doors, Walls, Elevators, Odors, The facility immediately conducted a review of all doors, walls, handrails, elevators, and areas where odors were identified. Maintenance staff corrected identified issues promptly by repairing or replacing missing door strips, ensuring all doors are properly locked, correcting paint chips on walls and handrails, cleaning walls, and addressing any sources of odors. In addition, chemicals and cleaning supplies were secured and stored out of reach of residents. The Executive Director and maintenance team conducted a facility-wide inspection to determine if other areas were affected and completed all necessary corrections. To prevent recurrence, staff were re-educated on routine inspections, reporting hazards, and maintaining environmental safety, including monitoring doors, walls, elevators, and odors. A standardized environmental inspection checklist has been implemented, with weekly inspections conducted by the Executive Director or designee. Any hazards identified during inspections will be corrected immediately by maintenance staff, and staff will be informed of findings during team meetings. Ongoing compliance will be monitored through weekly audits for 90 days, after which monitoring will transition to routine quality assurance review

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (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 the 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. A RCF 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 will be kept clean and in good repair.

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit.

Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with operational alarming devices or another acceptable system to alert staff when residents exited. Findings include, but are not limited to: A tour of the facility on 02/17/26 revealed exit doors leading into three secured courtyards located on the East and West Wings were not equipped with operational alarming devices or another acceptable system to alert staff when residents opened the doors. A tour of the environment was completed with Staff 2 (Co-owner), Staff 3 (ED/Human Resources), and Staff 4 (Assistant ED) on 02/18/26 at 11:04 am. They acknowledged the door alarms were not functioning.

Upon identification of the deficiency related to OAR 411-054-0200 (11–13) Call System, Exit Door Alarm, Phones, TV, or Cable, The facility immediately reviewed the resident call system, exit door alarms, and communication devices to ensure all were functional and accessible. Maintenance staff corrected identified issues promptly, including repairing or replacing call system devices, phones, and televisions as needed. To enhance resident safety, the facility will be installing door alarms on all doors that residents can exit through, ensuring staff are immediately alerted if a resident leaves an area and can confirm their safety when outside. The Executive Director and maintenance team conducted a facility-wide inspection to determine if other systems were affected and completed all necessary corrections. To prevent recurrence, staff were re-educated on the proper use of the call system, monitoring of exit doors, and environmental safety. A standardized communication and safety device checklist has been implemented, with weekly inspections conducted by the Executive Director or designee. Any issues identified during inspections will be corrected immediately by maintenance staff, and staff will be informed of findings during team meetings. Ongoing compliance will be monitored through weekly audits for 90 days, after which monitoring will transition to routine quality assurance review.

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit.

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit.

Based on interview and record review, it was determined the facility failed to ensure the individual and only appropriate staff had a key to access the unit for multiple sampled and unsampled residents who resided in the facility. Findings include, but are not limited to: In interviews on 02/18/26 with Staff 3 (ED/Human Resources) at approximately 12:15 pm and with Staff 11 (MT/CG) at 2:06 pm, both confirmed that no residents had keys to their units. The need to ensure the individual and only appropriate staff had a key to access resident units was discussed with Staff 2 (Co-owner) and Staff 3 on 02/18/26. They acknowledged the findings.

Upon identification of the deficiency related to OAR 411-004-0020 (2)(e) Individual Door Locks: Key Access, the facility immediately reviewed resident room door locks and corrected any deficiencies to ensure residents have secure and functional access to their personal rooms. Maintenance staff to ensure that keys are made and provided to each resident for their room, and that locks are functioning properly. To prevent recurrence, staff were r

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit.

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.

Based on interview and record review, the facility failed to ensure the move-in evaluation addressed all required elements, including pronouns and gender identity, for 1 of 1 resident (# 4) whose move-in evaluation was reviewed. Findings include, but are not limited to: Refer to C 252.

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.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Refer to C231, C362, C363, C420, C510, C513, and C555.

Refer to C231, C362, C363, C420, C510, C513, and C555.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 sampled newly-hired staff (#s 10 and 12) completed all required orientation and pre-service training before performing any job duties and 1 of 1 sampled newly-hired direct care staff (#10) completed pre-service training in all required training areas, and demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed with Staff 3 (ED/Human Resources) on 02/19/26 at 1:00 pm. The following was identified: Staff 10 (MT/CG) was hired 06/06/25 and Staff 12 (Activities Director) was hired 01/06/26. a. There was no documented evidence Staff 10 and Staff 12 completed orientation in: * Residents' rights and the values of community-based care; * Abuse and reporting requirements; and * Fire safety and emergency procedures. b. There was no documented evidence Staff 10 completed pre-service training in: * Environmental factors that are important to resident’s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); * Family support and the role the family may have in the care of the resident; * How to provide personal care to a resident with dementia, including an orientation to the resident and the resident’s service plan; and * The use of supportive devices with restraining qualities in memory care communities. c. There was no documented evidence Staff 10 had demonstrated competency in the following areas: * The role of service plans in providing individualized resident care; * Providing assistance with the activities of daily living; * Changes associated with normal aging; * Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition; * Conditions that require assessment, treatment, observation and reporting; and * General food safety, serving and sanitation. The need to ensure newly hired staff completed all required training was reviewed with Staff 3 on 02/19/26 at 1:00 pm, and with Staff 1 (Co-owner), Staff 5 (RN), and Staff 6 (Lead MT) on 02/19/26 at 3:20 pm. They acknowledged the findings.

Upon identification of the deficiency related to OAR 411-057-0155 (1–6) Staff Training Requirements, The facility immediately reviewed staff training records and corrected any gaps to ensure all staff had received required training. All new staff will receive mandatory trainings at the time of hire, and the Administrator and nursing leadership will ensure ongoing compliance by reviewing and verifying staff training completion at 30 days, 6 months, and annually. To prevent recurrence, staff were re-educated on training requirements, documentation standards, and timelines. The facility implemented a standardized staff training tracking system to ensure trainings are completed, documented, and updated timely. Ongoing compliance will be monitored through weekly audits of training records for 90 days, with any discrepancies corrected immediately, and after 90 days, monitoring will transition to routine quality assurance review.

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility.

Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Refer to C252, C260, C303, and C310.

Upon identification of the deficiency related to OAR 411-057-0160 (2)(b) Compliance with Rules – Health Care, The facility immediately reviewed current practices and resident health care documentation to ensure compliance with all applicable rules and regulations. Any deficiencies identified in care delivery, documentation, or policy adherence were corrected promptly, including updating care plans, verifying physician orders, and ensuring staff followed proper procedures. To prevent recurrence, staff were re educated on facility policies, OAR requirements, and proper documentation standards related to health care delivery. The facility implemented a standardized health care compliance checklist to monitor ongoing adherence to rules and regulations. The Executive Director or designee will audit resident records, care plans, and related health care documentation weekly for 90 days to ensure compliance, with any discrepancies corrected immediately and documented. After 90 days, monitoring will transition to routine quality assurance review.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility.

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities.

Based on observation, interview, and record review, it was determined the facility failed to evaluate the resident for activities and develop an individual activity plan based on their activity evaluation, for 3 of 3 sampled residents (#s 1, 2, and 3) whose activity plans were reviewed. Findings include, but are not limited to: During the survey, many sampled and unsampled residents were observed needing assistance and encouragement from staff to initiate, attend, and participate in activities. The facility offered group activities, which many residents attended. Some residents did not attend the activities and, instead, stayed in their rooms, sat in the common areas watching TV or falling asleep, or walked around the facility. All residents were diagnosed with some type of dementia. Resident 1, 2, and 3’s “90 Day Activity Evaluations” and current service plans were reviewed, and observations were made of the residents. The following was identified: Though the evaluations included some information about activity preferences, cognitive abilities and needs, and social interactions, the evaluations lacked a thorough evaluation of: * Past interests; * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Identification of activities for behavioral interventions. The facility did not use the information gathered in the activity evaluation to develop an individualized activity plan which detailed what, when, how, and how often staff should offer and assist the residents with more individualized activities. The need to develop individualized activity plans that were based on a thorough evaluation of the resident's activity interests, abilities, and needs was discussed with Staff 1 (Co-owner), Staff 3 (ED/Human Resources), and Staff 5 (RN) on 02/19/26 at 11:52 am and with Staff 1, Staff 3, Staff 5, and Staff 6 (Lead MT) 3:40 pm. They acknowledged the findings.

Upon identification of the deficiency related to OAR 411-057-0160 (2)(d) Activities, The facility immediately reviewed the activities plans for the identified resident(s) and corrected any deficiencies to ensure resident needs were addressed. Activities staff and nursing leadership ensured that meaningful activities are planned and documented for each resident at move-in and during the 90-day evaluation, reflecting individual preferences, abilities, and interests. The activities calendar was reviewed, updated, and will be maintained to ensure all planned activities are offered and followed consistently. To prevent recurrence, staff were re-educated on the requirements for documenting and implementing resident activities and on maintaining a current and accurate activities calendar. The Executive Director or designee will monitor compliance by auditing resident activities plans and the activities calendar weekly for 90 days to ensure that meaningful, resident-centered activities are occurring as planned. Any discrepancies identified will be corrected immediately and documented. After 90 days, monitoring will transition to routine quality assurance review.

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities.

Based on interview and record review, it was determined the facility failed to immediately investigate injuries of unknown cause in order to rule out suspected abuse or neglect and failed to report the injuries as suspected abuse, when abuse could not be ruled out, to the local Seniors and People with Disabilities (SPD) office for 1 of 1 sampled resident (#2), who was identified with injuries of unknown cause. Findings include but are not limited to: Resident 2 was admitted to the facility in August 2015 with diagnoses including dementia. Review of progress notes dated 03/04/23 through 05/24/23 identified the following injuries of unknown cause: * 03/06/23 bruise to left wrist was resolved; and * 04/04/23 bruise to left wrist. There was no documented evidence the facility immediately investigated how Resident 2 sustained the bruises to the left wrist in order to rule out abuse and neglect. The facility failed to notify the local SPD office as suspected abuse when abuse and neglect was not ruled out. The surveyor requested the facility self report the two incidents to the local SPD office on 06/08/23. The facility provided verification of reporting on 06/13/23. The need to investigate injuries of unknown cause in order to rule out suspected abuse or neglect and report to the local SPD office when abuse and neglect wasn't ruled out was discussed with Staff 1 (Executive Director), Staff 6 (Resident Services Coordinator), Staff 7 (Consultant), and Staff 8 (RN Consultant) on 06/08/23. They acknowledged the findings.

C231 OAR 411-054-0028 (1-3) Reporting & Investigating Abuse- Other Action 1. Immdiate action taken to correct this rule violation includes: Resident #2 brusies to left wrist on two occasions was reported to the local SPD office on 6/8/23 during survey. 2. To ensure the system will be corrected so this violation will not happen again all staff will be provided training on the following topics: incident report requirements, investigating incident reports, how to appropriately rule out abuse and neglect, implementing new interventions via TSP's, ensuring previous interventions and applicable service planning care were being followed to showcase rule out abuse and neglect secondary to 'as evidenced by' and when to report to local APS. 3. The area needing correction will be evaluated as follows:     a. Administrator and Licensed Nurse will coordinate with Business Office Manager daily at stand up to ensure that all staff have completed the required pre-service and on-going traning, 'Abuse and Reporting Requirements'     b. Incident reports will be reviewed at least five working days per week during morning stand-up with appropriate follow up being completed. 4. The Administrator, Licensed Nurse or designee will be responsible to ensure the system has been corrected and the system is monitored.

Based on observation, interview and record review, it was determined the facility failed to provide an activity program based on individual and group interests, physical, mental, and psychosocial needs, and opportunities for active participation in the community at large. Findings include, but are not limited to: The facility was divided into three units that included an assisted living, memory care east and memory care west. At the time of the survey the facility was home to 25 residents. Review of the current staffing plan identified the facility staffed four universal workers during the day shift and one activities person during the day shift and no activity person during swing or night shift. During an interview with Staff 14 (Cook/Resident Care Partner) on 06/07/23, s/he stated the caregivers were responsible for resident care, medication duties, all housekeeping duties, laundry service, all meal service including, cooking, serving, feeding assistance and cleaning. Staff 14 reported "we can do activities with residents when we have time." The 06/2023 Activity Calendar was reviewed. The following scheduled activities between 06/06/23 and 06/08/23 did not occur: * 06/06/23 - Morning chat all units 8:00 am, exercise 10:00 am in assisted living, puzzle time in memory care west 10:30 am, table activities in all units 11:00 am, walking group in memory care west at 1:00 pm and movie at 2:00 pm, and painting in the assisted living at 2:30 pm. * 06/07/23 - Morning chat all units 8:00 am, exercise in assisted living at 10:00 am and jewelry making at 10:30 am, bowling in memory care east at 11:00 am, walking group in memory care west at 1:00 pm and magazine reading at 2:00 pm, and Bingo in assisted living at 2:30 pm. * 06/08/23 - Morning chat all units 8:00 am, exercise in assisted living at 10:00 am, table activities in east memory care at 10:30 am and music hour at 11:00 am, board games in assisted living at 1:00 pm, walking group in west memory care at 1:30 pm, and nail time in all units at 2:30 pm. There were no planned activities that occurred and a television played continuously in the assisted living unit. In the memory care units residents were observed in their rooms or seen wandering the halls and sitting in common areas for long periods of time. During an interview with Staff 5 (Life Engagement Manager) on 06/08/23, it was reported the facility used to have an activities assistant who worked two days a week on Sunday and Monday to give Staff 5 time off. Staff reported the caregivers have access to activity items during those days, however, they are usually busy with other duties. The lack of an activity program was discussed with Staff 1(Executive Director), Staff 5, Staff 7 (Consultant), and Staff 8 (RN Consultant) on 06/08/23. They acknowledged the findings.

C242 OAR 411-054-0030 (1)(c-d) Resident Services: Activities 1. Immediate actions taken to correct this rule violation is as follows: * Administrator will complete an in-service training with all staff to address the expectation of activities when the Activitiy Director is not on-site, * Activity Director is interviewing each individual resident and updating 'The Story of a Lifetime' to reflect their current interests. * With each service plan update this information is being updated to be reflective on the service plan. 2. Activity Director will ensure that activity calendars are posted and supplies are available to meet the scheduled and unscheduled activities. 3. The area needing correction will be reviewed weekly, and then monthly to ensure resident activities are being offered daily seven days a week. 4. The Administrator, Activity Director or designee will be responsible to ensure the system has been corrected and the system is monitored.

Based on interview and record review, it was determined the facility failed to ensure quarterly evaluations were updated, were the basis for the development of the resident's service plan, available to staff and reflective of resident's care needs for 1 of 3 sampled residents (#3) whose move-in and quarterly evaluations were reviewed. Findings include, but are not limited to: Resident 3 was admitted to the facility in 09/2022 with diagnoses including Alzheimer's disease. An initial move-in evaluation dated 09/23/22 was provided by the facility. An updated quarterly evaluation was requested on 06/07/23 from Staff 7 (Consultant) at 10:17 am. There was no documented evidence an evaluation had been completed after the resident moved in. The need to ensure evaluations were performed quarterly, were the basis of the resident's service plan, available to staff and reflective of resident's care needs was discussed with Staff 1 (ED), Staff 6 (Resident Services Coordinator), Staff 7 and Staff 8 (RN Consultant) on 06/08/23 at 11:20 am. They acknowledged the findings.

C252 OAR 411-054-0034 (1-6) Resident Move-In and Eval: Res Evaluation 1. Resident #3 quarterly evaluation has been updated. 2. To ensure the system will be corrected so this violation will not happen again; evaulations including all required factors will be completed per company policy and Oregon Administrative Rule prior to move-in, updated within 30 days, quarterly thereafter with and with any significant change of condition. The document should be signed to indicate who completed the evaluation. 3. The area will need to be reviewed and audited on a quarterly basis via continuous quality improvement system. Completion and accuracy of evaluations will be reviewed in daily clinical stand-up meeting prior to each new move-in to ensure all components are reflective and all areas are complete with appropriate information. 4. The Administrator, Licensed Nurse or designee will be responsible to ensure the system has been corrected and the system is monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of resident needs, provided clear direction to staff regarding the delivery of services, and were completed initially and updated quarterly for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 07/2020 with diagnoses including dementia. Interviews with staff and review of the service plan, dated 10/31/22, revealed Resident 1's service plan was not updated quarterly. The need to ensure the service plans were updated at least quarterly was reviewed with Staff 1 (Executive Director), Staff 6 (Resident Services Coordinator), Staff 7 (Consultant) and Staff 8 (RN Consultant) on 06/08/23. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 09/2022 with diagnoses including Alzheimer's disease. There was no documented evidence the facility completed an initial service plan and updated it quarterly. The service plan was requested on 06/07/23 from Staff 7 (Consultant) at 10:17 am. No additional documentation was received at time of survey exit. The need to ensure service plans were completed initially and quarterly was discussed with Staff 1 (Executive Director), Staff 6 (Resident Services Coordinator), Staff 7 and Staff 8 (RN Consultant) on 06/08/23 at 11:20 am. They acknowledged the findings. 3. Resident 2 was admitted to the facility in 08/2015 with diagnoses including dementia. Observations of the resident's room, interviews with staff, and review of the service plan, dated 10/31/22, with hand written updates on 02/15/23, identified Resident 2's service plan was not updated quarterly, was not reflective of the resident's care needs and lacked clear direction to staff in the following areas: * Weight loss and interventions; * Oxygen use, instructions and equipment maintenance; * Ambulation; * Toileting assistance; and * Evacuation status, assistive devices and support. The need to ensure the service plans were updated at least quarterly, were reflective of the residents care needs and provided clear direction to staff was reviewed with Staff 1 (Executive Director), Staff 6 (Resident Services Coordinator), Staff 7 (Consultant) and Staff 8 (RN Consultant) on 06/08/23. They acknowledged the findings.

C260 OAR 411-054-0036 (1-4) Service Plan: General 1. Resident #1 quarterly service plan will be updated. Resident #3 initial service plan will be completed. Resident #2 quarterly service plan will be updated and reflects clear directions to staff in the following areas: * Weight loss and interventions; * Oxygen use, instructions and equipment maintenance; * Ambulation * Toileting assistance; and * Evacuation status, assistive devices and support. 2. This system will be corrected so this violation does not happen again by ensuring that the service plan is updated with pre-scheduled (initial, 30-day and quarterly) and any acute or significant change of condition to reflect the residents current status per Oregon Administrative Rule. Clinical services and Administrator partcipate with this process to ensure accuracy and personalization. 3. The area needing correction will be evaluated at time of move-in, 30-day review, quarterly, and as needed if a change of condition occurs. 4. The Administrator, Licensed Nurse or designee will be responsible to ensure corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the residents choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 2 of 3 sampled residents (#s 2 and 3) whose service plans were reviewed. Findings include, but are not limited to: a. Resident 2's most recent service plan lacked documentation that a Service Planning Team reviewed and participated in the development of the service plan. b. There was no documented evidence that a service plan was completed and developed by a service planning team for Resident 3. The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Executive Director), Staff 6 (Resident Services Coordinator), Staff 7 (Consultant) and Staff 8 (RN Consultant) on 06/08/23. They acknowledged the findings.

C262 OAR 411-054-0036 (5) Service Plan: Service Planning Team Meeting 1. Immediate actions taken to correct the rule violation include: Resident # 2 and Resident #3 service plans will be updated with evidence that the resident and / or residents 'legal respresentative / person of residents' choice, the facility Administrator or designee, and at least one other staff person familiar with their provided services partcipated. 2. To ensure the system will be corrected so this violation will not happen again; the service plans will be developed by a service planning team. Monthly service plan review schedule has been set up to ensure timely reviews take place consistently. An invitation will be extended to family / person of residents choice to attend service plan team meeting. All those in attendance will review and sign the service plan. Those not able to attend will be sent a copy of the service plan for review and signature. Signature page will then be attached to the service plan. 3. The area will need to be evaluated at resident move-in, 30-day review and quarterly update and  / or as needed if signifcant change of condition occurs. 4. The Administrator, Licensed Nurse or designee will be responsible to ensure corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure residents who experienced short-term changes of condition had resident-specific actions/interventions and/or changes were monitored at least weekly to resolution for 3 of 3 sampled residents (#s 1, 2 and 3) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 07/2020 with diagnoses including dementia. Interviews with staff, review of the service plan dated 10/31/22, temporary service plans, incident investigations and progress notes dated 04/04/23 through 06/08/23 were reviewed. The resident experienced multiple short-term changes without documented evidence resident-specific instructions or interventions were developed and communicated to staff, nor was the condition monitored at least weekly to resolution in the following areas: * 04/25/23 - cyst on left eyelid; * 04/25/23 - laceration on left finger; and * 05/03/23 - cellulitis on right leg. The need to ensure short-term changes of condition had documented evidence the condition was referred to the nurse, resident-specific instructions or interventions were developed and communicated to staff, the condition was monitored at least weekly to resolution was discussed with Staff 1 (Executive Director), Staff 6 (Resident Services Coordinator), Staff 7 (Consultant) and Staff 8 (RN Consultant) on 06/08/23. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 09/2022 with diagnoses including Alzheimer's disease and had a history of falls. Interviews with staff, review of the initial move-in assessment dated 09/23/22, temporary service plans, incident investigations and progress notes dated 04/11/23 through 06/06/23 were reviewed. The following changes of condition lacked documented evidence interventions were identified and communicated to staff on each shift: * 05/01/23 - Bruise on left forearm; * 05/08/23 - Aggressive behavior of repeatedly pushing a locked door; and * 05/23/23 - Fall outside in the courtyard. The need to ensure the facility communicated changes of condition including monitoring instructions and interventions to staff on each shift and made the interventions part of the resident's record was discussed with Staff 1 (Executive Director), Staff 6 (Resident Services Coordinator), Staff 7 (Consultant) and Staff 8 (RN Consultant) on 06/08/23. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 08/2015 with diagnoses including dementia. Interviews with staff, review of the service plan, dated 10/31/22, with hand written updates dated 02/15/23, temporary service plans, weight records and progress notes, dated 03/04/23 through 05/24/23, were reviewed. Resident 2 experienced multiple short-term changes of condition that lacked evidence resident-specific instructions or interventions were developed and communicated to staff, the documentation of staff instructions or interventions was made part of the resident record with weekly progress noted until the condition resolved in the following areas: * 02/03/23 - Weight loss and interventions; * 03/04/23 - ER visit, dehydration and new medication (Zofran); * 03/06/23 - bruise on left wrist; * 03/17/23 - rash under breast; * 03/17/23 - resident refused multiple medications; * 03/31/23 - emesis; * 04/04/23 - bruise on left wrist; * 04/04/23 - sharp right upper chest pain, ER visit and new diagnosis of pleurisy (fluid buildup in the lining of the lungs); * 05/03/23 - discontinued medications Lisinopril, Furosemide, and Vitamin B-12; and * 06/06/23 - discontinued scheduled Lidocaine patch for pain. The weight loss identified on 02/03/23 was assessed by an RN and included an intervention to obtain weekly weights however, the intervention was not communicated to staff. The need to ensure short-term changes of condition had resident-specific instructions or interventions developed, communicated to staff, the documentation of staff instructions or interventions were made part of the resident record with weekly progress noted until the condition resolved was discussed with Staff 1 (Executive Director), Staff 6 (Resident Services Coordinator), Staff 7 (Consultant) and Staff 8 (RN Consultant) on 06/08/23. They acknowledged the findings.

C270 OAR 41-054-0040 (1-2) Change of Condition and Monitoring 1. The following actions will be taken to correct this rule violation. Resident #1 will have a comprehensive nursing assessment and appropriate follow up completed related to cyst on left eyelid, laceration on left finger; and cellulitis on right leg. Resident #2 will have a comprehensive nursing assessment and appropriate follow up completed related to weight loss and interventions, ER visits, dehydration, new medication, bruises on left wrist, rash under breast, refusal of medications, emesis, sharp upper right chest pain, new diagnosis of pleurisy, and medication changes. Resident #3 will have a comprehensive nursing assessment and appropriate follow up completed for bruise on left forearm, aggressive behavior of repeatedly pushing a locked door; and fall outside in the courtyard. 2. To ensure the system will be corrected so this violation will not happen again, a 24-hour communication system is in place to include: a. Shift to Shift Communication. b. Alert Charting Log / Audit Tool c. Signifcant Change of Condition Log d. Weekly Skin Monitoring Log Staff will start short term monitoring / communication system for any resident identified to have a an acute change of condition such as skin concerns / issues, return from higer level of care, missed and / changed medications or fall for an example. When a change of condition is identified, staff add the resident name to alert log to ensure they monitor resident and identify when to report concerns to nursing / physician. The staff will be aware of what to report to the nurse / physician per the temporary service plan (TSP) that has been put in place, which correlates with resident of change of condition. The TSP has specific directions for staff including what to look for, interventions to put in place, signs and symptoms to report and staff signature lines to sign once they have read and understood the TSP. Staff should monitor resident status until resident condition resolves, and they are back to their baseling. 24- hour book / process will be reviewed daily during clinical review as a means of identification of potential signifcant change that needs to be assessed by the RN. 3. The area needing correction will be reviewed daily, weekly, monthly and quarterly to ensure compliance is maintained. 4. The Administrator and Registered Nurse will be responsible to ensure the corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to establish and maintain effective infection prevention and control protocols for 1 of 1 sampled resident (#2) and during meal service. Findings include, but are not limited to: Observations made during the survey, 06/06/23 through 06/08/23, determined the facility failed to adhere to universal precautions for infection control in the following areas: 1. Resident 2 was admitted to the facility in 08/2015 with diagnoses including dementia. Observations and interviews with staff during the survey identified s/he was unable to transfer from bed and relied on staff for incontinence care needs. On 06/07/23 at 11:20 am, the surveyor obtained permission from the resident and observed Staff 14 (Cook/Resident Care Partner) provide ADL incontinent care. During the observation, Staff 14 donned gloves without performing hand hygiene. Staff 14 failed to doff soiled gloves, perform hand hygiene and don clean gloves before touching the resident's body and clean incontinent products. Staff 14 then proceeded to remove the soiled incontinent brief, cleanse the residents perineum area and applied barrier cream to the residents skin while wearing soiled gloves. Staff 14 was observed to immediately enter another resident's room to assist the resident without performing hand hygiene. The above observation was discussed with Staff 8 (RN Consultant) on 06/08/23 at 3:38 pm. She acknowledged appropriate infection control practices were not implemented. 2. During the survey, from 06/06/23 through 06/08/23, multiple care staff who performed universal duties, including resident ADL care, were observed to assist with meal service. Care staff were not wearing aprons or some other barrier to prevent the potential for cross contamination when assisting with meal service. The need to ensure staff consistently used universal precautions was discussed with Staff 1 (Executive Director), Staff 6 (Resident Services Coordinator), Staff 7 (Consultant) and Staff 8 on 06/08/23. They acknowledged the findings.

C295 OAR 411-054-0050 (1-5) Infection Prevention & Control 1. Action taken to correct this violation includes: * All staff will trained on infection Prevention and Control policies and procedures related to donning / daffing person protective equipment, the use of gloves, hand hygiene and handling of soiled products. * Aprons are being purchased for universal workers that provider care and assist with meal services. 2. The system will be corrected so this violation will not happen again by ensuring the staff are trained upon hire, during all staff trainings and annually on Infection Prevention and Control Polices. The Administrator is completing the Infection Control Specialist Training. 3. The area needing correction will be evaluated daily, weekly and monthly during quality improvement walk throughs. 4. The Administrator, Licensed Nurse or designee will be responsible to ensure the corrections are completed and monitored.

Based on interview, and record review, it was determined the facility failed to ensure an accurate MAR was kept for all medications that were ordered by a legally recognized provider and administered by the facility, for 1 of 4 sampled residents (#2) whose MARs were reviewed. Findings include, but are not limited to: Resident 2's 05/01/23 through 06/05/23 MARs and signed physician orders, dated 05/05/23, were reviewed during the survey. The following inaccuracies were identified: a. Resident 2 was prescribed Hydrocodone, as needed, for pain. During an interview with Staff 8 (RN Consultant) on 06/08/23 at 2:35 pm it was reported the pharmacy didn't have an active order therefore, the medication was not delivered to the facility and the medication was not removed from the MAR. b. Resident 2 was prescribed continuous oxygen 2 LPM (liters per minute). The order was not transcribed onto the MAR and the facility failed to document administration of the treatment. c. Resident 2 was prescribed zinc oxide barrier cream to be applied after each incontinent episode. The facility staff failed to document on the 05/01/23 through 06/05/23 MARs the barrier cream was being applied during the incontinent changes. The need to ensure MAR's were accurate was discussed with Staff 1 (Executive Director), Staff 6 (Resident Services Coordinator), Staff 7 (Consultant) and Staff 8 on 06/08/23. They acknowledged the findings.

C310 OAR 411-054-0055 (2) Systems; Medication Administration 1. Immediate action taken to correct this rule include:     Resident #2 MAR will be reviewed and updated to the reflect the following; oxygen and zinc barrier with clear instructions for use. 2. The system will be corrected so this violation will not happen again by ensuring trained staff perform daily MAR audits to ensure no holes. and All physician orders will go through a triple check system where the order is initially processed by the receiving med tech to ensure  no delay in treatment. 2nd check is the next oncoming med tech or RCC to verify orders area accurate, and appropriate directions and parameters for staff to follow are in place. Nursing will be final check to verify all components are in place, and to make updates as indicated. 3. The area needed correction will be reviewed daily, weekly, and monthly basis with triple check, MAR audits and monthly continuous qualtiy improvement program. All orders will be reconciled quarterly prior to phyisican orders being sent physician for review. 4, The Licensed Nurse, RCC, or trained designee will be responsible to ensure the corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure MARs were accurate, included medication specific instructions, and had resident-specific parameters and instructions for PRN medications for 3 of 4 sampled residents (#s 7, 8, and 10) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 7 moved into the facility in 08/2023 with diagnoses including Parkinson's disease. Resident 7's MAR dated 12/01/23 through 01/01/24 was reviewed during survey and revealed the following: a. The following PRN medications prescribed for constipation lacked resident-specific parameters and instructions to staff: * Bisacodyl 10 mg suppository; * Phosphate/saline enema; * Milk of Magnesia 400 mg/5 mL; and * Polyethylene glycol 3350 powder. In an interview with Staff 11 (MT/CG) on 01/03/24 at 1:30 pm, she confirmed the PRN bowel medications lacked resident-specific parameters and instructions in the electronic MAR. b. The MAR was blank for the following medications on 12/30/23: * Acetaminophen 500 mg (for pain); * Carbidopa-levodopa 25 mg/100 mg (for Parkinson's disease); * Docusate/senna 25 mg/100 mg (for bowel care); * Gabapentin 300 mg (an anticonvulsant); * Lidocaine 5% patch (for pain); * Pramipexole 0.5 mg (for Parkinson's disease); * Propranolol 20 mg (for high blood pressure); * Quetiapine 25 mg (a psychotropic); and * Rivastigmine 1.5 mg (for dementia). On 01/03/24 at 1:30 pm, the surveyor and Staff 11 (MT/CG) reviewed the MAR and checked the medication cart. Staff 11 verified the medications had been administered, but staff failed to document on the MAR. The need to ensure MARs were accurate and PRN medications included resident-specific parameters and instructions to unlicensed staff was discussed with Staff 2 (ED) and Staff 20 (RN) on 01/04/23. They acknowledged the findings. 2. Resident 8 was admitted to the facility in 12/2023 with diagnoses including dementia and  type 2 diabetes mellitus with use of insulin. Resident 8's MAR from 12/28/23 through 01/02/24 and physician orders were reviewed and revealed the MAR lacked specific instructions for administration of the insulin glargine 100U/ml pen (to control blood glucose level). The medication record had the following instructions for insulin glargine administration: "Inject 50 units subcutaneously daily at bedtime. Use 2 units to prime prior to each administration." Injecting insulin glargine in accordance with the specific instructions on the MAR would result in 48 units being administered, which was not in accordance with the physician order. On 01/03/24 at 4:00 pm, Staff 25 (MT/CG) demonstrated to the surveyor how to prepare and administer the proper dose of insulin glargine by following the facility written instructions located in the Nursing Delegation binder. The need to ensure MARs were accurate and contained medication specific instructions was reviewed with Staff 2 (ED) and Staff 20 (RN) on 01/04/24. They acknowledged the findings. No further information was provided. 3. Resident 10 moved into the facility in 03/2021 with diagnoses including dementia and constipation. Resident 10's MAR dated 12/01/23 through 01/02/24 was reviewed during survey and revealed the following: a. Two PRN medications, Diclofenac 1 % gel and Tramadol 50 mg tablet were prescribed for hip pain. The MAR lacked resident-specific parameters and instructions to staff. Both PRN medications were administered on multiple occasions during the review period. In an interview with Staff 26 (MT/CG) on 01/03/24 at 9:21 am, she confirmed the PRN pain medications lacked resident-specific parameters and instructions in the electronic MAR. b. The MAR was blank on scheduled Acetaminophen 1000 mg (for pain) medication on 12/01/23 and 12/18/23. On 01/03/24 at 9:28 am, the surveyor and Staff 3 (Resident Services Coordinator) reviewed the MAR and checked the medication cart. Staff 3 verified the medications had been administered, but staff failed to document on the MAR. The need to ensure MARs were accurate and PRN medications included resident-specific parameters and instructions to unlicensed staff was discussed with Staff 2 (ED) on 01/03/24 at 11:10 am. She acknowledged the findings.

C-310 OAR 411-054-0055 (2) Systems: Medication Administration 1. Actions taken to correct this rule violation include: a. Resident #7 The following PRN medication(s) prescribed for consitpation have the resident-specific parameters and instructions to staff added:          Bisacodyl 10mg Suppository;          Phosphate / Saline Enema;          Milk of Magnesia 400 mg / 5ml; and          Polyethylene Glycol 3350 Powder. On 12/30/23 the MAR was blank for the following medication(s):          Acetaminophen 500mg (for pain);          Carbidopa-levodopa 25mg / 100mg (for Parkinson's Disease);          Docusate / Senna 25mg / 100mg (for bowel care);          Gabapentin 300mg (an anticonvulsant);          Lidocaine 5% patch (for pain);          Pramipexole 0.5mg (for Parkinson's Disease);          Propranolol 20mg (for high blood pressure);          Quetiapine 25mg (a psychotropic); and          Rivastigmine 1.5mg (for dementia) Licensed nurse has completed a medication error report with investigation and provided teaching and training to the med techs. b. Resident #8 Specific instructions have been added to the MAR for insulin glargine administration. The 'use 2 units to prime prior to each administration' has been removed from the instructions. c. Resident #10 The following PRN medication(s), Diclogenac 1% gel and Tramadol 50mg tablet for hip pain, have had resident-specific parameters and instructions to staff added. On 12/1/23 and 12/18/23 the MAR was blank for the following medication(s):          Acetaminophen 1000mg (for pain) Licensed nurse has completed a medication error report with investigation and provided teaching and tranining to the med techs. 2. The system will be corrected so this violation will not happen again by ensuring training community staff perform daily MAR audit to ensure no holes / missed medication(s) / treatment(s). All new physican orders go through a triple check where the order is initially processed by the receiving med tech / RCC to ensure no delay of treatment. Second check is the next oncoming med tech / RCC to verify orders are accurate, and appropriate directions and parameters for staff to follow are in place. Nursing to be the final check to verify all components are in place, and to make updates as indicated. Trained staff will completed bi-weekly, weekly and monthly MAR audits to ensure any concerns with medication decrepancy, omissions, PRN effectiveness, and parameters are followed up on timely. 3. The area needing correction will be reviewed daily, weekly and monthly basis with triple check MAR audits and monthly continous quality improvement program. All orders will be reconciled quarterly prior to physician orders being sent to physicians for review. 4. The Administrator, Licensed Nurse, RCC or trained designee will be responsible to ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to update an acuity-based staffing tool (ABST), no less than quarterly for all residents and address all the activities of daily living (ADLs) for each resident, including the amount of staff time needed to provide care. Findings include, but are not limited to: A review of the ABST being used by the facility and an interview with Staff 1 (Executive Director) on 06/07/23 identified the following: * The facility had not completed quarterly updates of the ABST tool for residents residing in the "west memory care unit"; and * During interviews with staff and observations of resident care, the current ADL needs for multiple sampled residents were not reflective in the ABST, including an accurate amount of staff time needed to provide care. The need to ensure all time needed for providing ADL care to residents was accurate and all residents were updated in the ABST tool, at least quarterly, was reviewed with Staff 1 on 06/07/23 and 06/08/23. No additional information was provided.

C361 OAR 411-054-0037 (1-8) Acuity- Based Staffing Tool 1. Actions taken to correct the rule violation include: * Service plans are actively being updated as each one is updated Administrator is adding the required information to the ABST. 2. The system will be corrected to ensure this violation will not happen again as follows:     a. Facility will ensure that policies and procedures are in place for the required acuity-based staffing tool.     b. Facility will maintain ABST and the ABST will be updated with each resident evaluation; initial, within 30-days of admission, quarterly, and with signifcant change of condtion.     c. Administrator will review staffing schedule to ensure that the schedule is reflective of staffing requirements based on the ABST. 3. The area needing corrected will be evaluated monthly to ensure that the staffing schedule is reflective of staffing needs based on resident care needs, per the ABST. 4. The Administrator or deisgnee will be responsible for ensuring the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to document all required elements of fire drill documentation, and provide fire and life safety instruction to staff on alternate months per the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety records dated 01/2023 through 05/2023 were reviewed on 06/07/23. The following was identified: 1. Fire drill documentation did not include the following required elements: * Problems encountered, comments relating to residents who resisted or failed to participate in the drills. 2. There was no documented evidence the facility was providing fire and life safety instruction to staff on alternating months. The need to follow OFC requirements pertaining to fire drills, documentation, and staff training was discussed with Staff 1 (Executive Director) and Staff 4 (Maintenance Director) on 06/07/23. They acknowledged the findings.

C420 OAR 411-054-0090 (1-2) Fire and Life Safety: Safety 1. Action take to correct the rule violation will include: a. Facility will conduct unannouced fire drills every other month at different times of the day, evening, and night. b. Fire and life safety instruction to staff will be provided on alternate months. c. Written fire drills will be kept that include but not limited to: * Problems encountered, comments relating to residents who resisted or failed to partcipate in the drills 2. The system will be corrected so this violation does not happen again by completing a comprehensive review of current fire drill forms to ensure they meet the requirements of the Oregon Administrative Rule and in-servicing administration or designee conducting fire and life safety drills and education on process and documentation required. 3. The area needing correction will be evaluated monthly. 4. The Administrator or designee will be responsible to ensure corrections are completed and montiored.

Based on interview and record review, it was determined the facility failed to ensure residents received fire and life safety training at least annually. Findings include, but are not limited to: Fire and life safety records were requested during the survey. The following was  identified: *The facility lacked documentation of annual fire and life safety training provided to residents. The need to ensure residents received fire and life safety training at least annually was discussed with Staff 1 (Executive Director) and Staff 4 (Maintenance Director) on 06/07/23. They acknowledged the findings.

C422 OAR 41-054-0090 (5) Fire and Life Safety: Training for Residents 1. Immediate action taken to correct this rule violation includes all residents will be instructed on 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, and reinstructed annually. 2. The system will be corrected so this violation will not happen again by ensuring new residents will be instructed with 24 hours of move-in and re-instructed annually for 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. 3. The area needing correction will be audited daily at stand-up meeting and clinical meeting with a new resident move-in. 4. The Administrator and / or designee will be responsible to ensure corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to provide handrails at one or both sides of resident-use corridors. Findings include, but are not limited to: The interior of the building was toured on 06/07/23. The corridors of the main entrance leading to the common area and the corridor leading to the "east memory care unit" were observed without a handrail on at least one side of the corridor. On 06/07/23, the need to ensure handrails were installed along resident use corridors was discussed with Staff 1 (Executive Director) and Staff 4 (Maintenance Director). They acknowledged the findings.

C511 OAR 411-054-0200 (4)(a-b) General Building Interior 1. Immediate action taken to correct this rule violation is the Maintenance Director has requesting bid's from contractors to place handrail in the following areas: * Corridor of the main entrance leading to the common area and * Corridor leading to the 'east memory care unit' 2.The system will be corrected so this violation will not happen again by completing consistent environmental walk throughs to ensure handrails are installled at one or both sides of resident-use corridors and are in good repair and any concerns are identified and followed up on timely. 3.The area needing correction will be evaluated on a monthly basis with environmental audit. 4. The Administrator, Maintenance Director or designee will be responsible to ensure corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean and in good repair. Findings include, but are not limited to: Observations made on 06/06/23 and 06/07/23 revealed the following areas needed cleaning or repair: 1. In the "East Memory Care Unit": * Multiple chairs in the living room/tv area had peeling fabric and worn leather, exposing the fibers underneath. There were food particles and trash in the cup holders; * A section of baseboard was missing on the wall near the unit entrance/exit; and * Multiple window screens along the east side of the building were torn and had holes along the bottom perimeter of the screens. 2. In the "Open Unit": * There was a missing electrical wall plate near the TV in the common area living room. The environment was toured on 06/07/23 with Staff 1 (Executive Director) and Staff 4 (Maintenance Director). The need to ensure all interior and exterior materials and surfaces were kept clean and in good repair was discussed with Staff 1 and Staff 4. They acknowledged the findings.

C513 OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors 1. Immediate action taken to correct this rule violation includes: East Memory Care: * Mulitple chairs in the living room / tv area with peeling fabric and worn leather, exposing the fibers underneath will be replaced. Food particles and trash in the cup holders have been cleaned. * Section of baseboard has been replaced that was missing on the wall near the unit entrance / exit. * Window screens along the east side of the building that are torn and have holes along the perimeter of the screens are being repaired / replaced. Open Unit: * Electrical wall plate near the TV in the common area living room has been replaced. 2.The system will be corrected so this violation will not happen again by completing consistent environmental walk throughs to ensure furniture is in good condition and clean, all baseboards are in place, screens on windows are in good repair with no tears or holes, and all electrical wall plates are in place and any concerns are identified and followed up on timely. 3.The area needing correction will be evaluated on a monthly basis with environmental audit. 4. The Administrator, Maintenance Director or designee will be responsible to ensure corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to ensure laundry facilities were located to allow for resident use, washing machines had a minimum rinse temperature of 140 degrees Fahrenheit or used a chemical disinfectant when washing soiled linens and soiled clothing, and ensure the separate storage and handling of soiled linens and soiled clothing. Findings include, but are not limited to: The three facility laundry rooms were observed on each unit on 06/06/23 and 06/07/23. The were observed: a. The facility had both commercial and residential type washers. During an interview on 06/07/23, Staff 4 (Maintenance Director) stated there was no way to determined the rinse temperature. The detergent the facility used did not include a disinfecting agent to use on soiled linens. b. During an interview on 06/08/23 with unsampled residents on the "Open Unit", residents stated there were no laundry facilities available if they chose to do their own laundry. Staff 1 (Executive Director) stated there were no residents currently requesting to do their own laundry and acknowledged no process had been identified for them to do so. c. During an interview on 06/06/23, Staff 10 (Resident Care Partner) stated soiled linens were washed in the laundry facilities in the "West Memory Care Unit". There was no separate area in the west unit for handling soiled linens and clothing. In an interview on 06/07/23, Staff 1 and Staff 4 acknowledged the facility was lacking a process for soiled linen processing. The need to ensure soiled laundry was properly disinfected, a resident laundry room was available for resident use, and the facility was following a soiled linen process was discussed with Staff 1 and Staff 4 on 06/07/23. They acknowledged the findings.

C530 OAR 411-054-0200 (7)(b-d) Housekeeping and Laundry 1. The action taken to correct this violation is: * The facility is working with EcoLab for an option for a disinfecting agent to use on soiled linens. * Stackable washer / dryer is being purchased and will be installed in the 'Open Unit' laundry room for the residents to use to wash his / her laundry. * Hopper is being installed in the 'Open Unit' for use of soiled linen. 2. The system will be corrected so this violation will not happen again by completing consistent environmental walk throughs to ensure the disinfecting agent is being utilized for all soiled linens, all residents in the 'Open Unit' will be trained on the use of the stackable washer / dryer, and all staff will be provided with in-servicing on the soiled linen process. 3.The area needing correction will be evaluated on a monthly basis with environmental audit. 4. The Administrator, Maintenance Director or designee will be responsible to ensure corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure washing machines had a minimum rinse temperature of 140 degrees Fahrenheit or used a chemical disinfectant when washing soiled linens and soiled clothing, and ensure the separate storage and handling of soiled linens to preclude potential for contamination of clean linens and clothing. This is a repeat citation. Findings include, but are not limited to: Facility laundry rooms were observed on the East Unit, West Unit and Open Unit from 01/02/24 through 01/04/24. The following deficiencies were identified: 1. Facility policy for soiled linens and clothing stated items were to be bagged, brought to the East Unit laundry room, any debris rinsed in the flushing rim clinical sink, placed in the washing machine, and washed using laundry detergent and the chemical disinfectant provided by the facility. The facility washing machines did not offer a minimum rinse temperature of 140 degrees F. Interviews during the survey identified the following inconsistencies with the process for rinsing soiled linens and using a chemical disinfectant: a. Staff 10, 11, 19 and 22 (CG's) stated they used laundry detergent but did not say they used the chemical disinfectant. b. Staff 14 (CG) stated soiled linens were rinsed off in residents' private bathroom toilets. c. Staff 26 (CG) stated the utility sink was used, not the flushing rim clinical sink, to rinse soiled items. 2. The facility stored clean bedding/linens, reusable bed pads and plastic hangers in the East Unit laundry room in close proximity to the flushing rim clinical sink used for pre-rinsing soiled laundry. The need to ensure soiled laundry was properly disinfected and the facility was storing clean laundry separately from where soiled laundry was processed was discussed with Staff 1 (ED) and Staff 4 (Maintenance Director) on 01/04/24. They acknowledged staff were not consistently following the facility process for laundering soiled items and agreed to relocate the clean linen storage.

C530 OAR 411-054-0200 (7)(b-d) Housekeeping and Laundry 1.       a. Staff 10, 11, 19, and 22 have been retrained individually regarding the use of the chemical disinfectant by the maintenance director. b. Staff 14 has been retrained on the facility policy for soiled linens and clothing. c. Staff 26 has been retraining on the use of the flushing rim clinical sink, to rinse soiled items. Laminated sign has been placed on the utility sink that reads as follows, ' Do not use utility sink for rinsing soiled laundry. Use flushing rim clinical sink only', d. The clean bedding / linens, reusable bed pads and plastic hangers in the East Unit laundry room has been removed. e. The facility policy for soiled linens and clothing has been laminated and placed in laundry rooms on East Unit, Open Unit and West Unit. 2. The system will be corrected so this violation will not happen again by completing consistent environmental walk throughs to ensure the disinfecting agent is being utilized for all soiled linens, and all staff will be provided with in-servicing on the soiled linen process. 3.The area needing correction will be evaluated on a daily, weekly and monthly basis with environmental audit. 4. The Administrator, Maintenance Director or designee will be responsible to ensure corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to ensure that a manually operated emergency call system was provided in each toilet facility used by residents and visitors. Findings include, but are not limited to: The facility was toured on 06/07/23 with Staff 1 (Executive Director) and Staff 4 (Maintenance Director). A restroom located in the "Open Unit," used by residents and visitors, did not have a manually operated emergency call device. The need to provide a manually operated emergency call system in all toilet and bathing facilities used by residents and visitors was discussed with Staff 1 and Staff 4. They acknowledged the findings.

C555 OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable 1. Immediate actions taken to correct this violation include a manually operated emergency call device has been installed in the 'Open Unit' restroom that is used by both residents and vistors. 2. The system will be corrected so this violation does not happen again by monthly facilities audits of all restrooms utilized by residents and visitors have manually operated emergency call devices installed and are operable. 3. The area needing correction will be evaluated weekly and monthly via maintenance log review and community walk through. 4. The Administrator and Maintenance Director will be responsible ensuring corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 231, C 242, C 295, C 361, C 420, C 422, C 511, C 513, C 530 and C 555.

Z172 OAR 411-057-0140 (2) Administration Compliance Reference C 231, C 242, C 295, C 361, C 420, C 422, C 511, C 513, C 530 and C 555

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 530.

Z142 OAR 411-057-0140(2) Administration Compliance Refer to C530

Based on interview and record review, it was determined the facility failed to have documented evidence of required pre-service orientation and dementia training completed, demonstrated competency in assigned duties within 30 days of hire for 3 of 3 newly hired direct care staff (#s 15, 16 and 17) , and a total of 16 hours of in-service training completed annually, including six hours related to dementia care topics for 2 of 3 long-term direct care staff (#s 18 and 19) . Findings include, but are not limited to: Staff training records were reviewed with Staff 2 (Business Office Manager) and Staff 6 (Resident Services Coordinator) on 06/06/23 and 06/08/23. 1. Training records for Staff 15 (MT/Resident Care Partner), Staff 16 (Resident Care Partner), and Staff 17 (Resident Care Partner), hired 04/19/23, 04/04/23, and 03/21/23 respectively, identified the following: a. Staff 15, 16 and 17 lacked documented evidence pre-service orientation training was completed prior to beginning job responsibilities in the areas of: * Resident rights and values of community based care; * Abuse reporting requirements; * Fire safety and emergency procedures; and * Infectious disease prevention. b. Staff 15, 16 and 17 lacked documented evidence pre-service dementia training was completed prior to independently providing care and services to residents. c. Staff 15, 16 and 17 lacked documented evidence of knowledge and performance demonstrated within 30 days of hire in the following required 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 * Other duties as applicable, including safe medication and treatment administration. 2. Staff 18 (Resident Care Partner) and Staff 19 (Resident Care Partner), hired 05/01/10 and 05/31/19 respectively, lacked documented evidence of completion of 16 hours of annual in-service training which included at least six hours of dementia care training annually from 05/2022 to 05/2023. The need to ensure all required training was completed in the specified time frames was reviewed with Staff 1 (Executive Director) and Staff 2 on 06/08/23. They acknowledged the findings.

Z155 OAR 411-057-0155 (1-6) Staff Training Requirements 1. Immediate actions taken to correct the rule violation include ensuring staff #15, #16 and #17 have documented evidence of completing training in the following areas: Pre-Service Orientation * Resident rights and values of community based care; * Abuse reporting requirements; * Fire safety and emergency procedures; and * Infectious disease prevention * Pre-service dementia training And Knowledge and Performance Demonstrated * Role of service plans in providing individualized care * Providing assistance with ADL's * Changes associated with normal aging * Indentification, documentation, and reporting of changes of condition * Conditions which requires assessment, treatment, observation, and reporting; * General food safety, serving, and sanitation; * Other duties as applicablem including safe medication and treatment administration. and Staff #18 and #19 have documented evidence of completing traning in the following areas: * 16 hours of annual in-service training which includes at least six hours of dementia care training. 2. To ensure the system is corrected so the violation will not happen again by: * Completing a comprehensive training record audit of all trainings and competencies completed and documented on a training log for review. * Any missing competencies and trainings will be completed for currenlty employed staff. * Staff will utilize a combination of Oregon Care Partners, Relias, med tech training meetings, and monthly staff meetings to meet the annual in-servicing requirements. * Staff will submit certifcate of completion or evidence of participation at facility provided trainings for documentation. 3. The area needing correction will be evaluated weekly and monthly via review of newly hired staff and training log review. 4. Business Office Manager, Administrator or designee will be responsible to see that the corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 252, C 260, C 262, C270 and C 310.

Z162 OAR 411-057-0160 (2b) Compliance with Rules Health Care Reference C 252, C 260, C262, C 270 and C 310

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 310.

Z162 OAR 411-057-0160(2b) Compliance with Rules Health Care Reference C310

Based on interview, and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 2 of 2 sampled memory care residents (#s 1 and 3) whose records were reviewed. Findings include, but are not limited to: a. Resident 1 and 3's "The Story of a Lifetime" form offered some historical information about the resident's previous interests, hobbies, and occupations; however, the facility failed to evaluate the resident's: * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Identification of activities for behavioral interventions. b. Resident 1 and 3 lacked an individualized activity plan which detailed what, when, how and how often staff should offer and assist the residents to participate in group activities or assist with providing more individualized activities. In an interview on 06/08/23 at 9:45 am, Staff 5 (Life Engagement Manager), stated she was the only activity person and reported she was not involved in the service planning meetings. The need to ensure an individualized activity plan was developed for each resident based on their activity evaluation was reviewed with Staff 1 (Executive Director), Staff 6 (Resident Services Coordinator), Staff 7 (Consultant) and Staff 8 (RN Consultant) on 06/08/23. They acknowledged the findings.

Z164 OAR 411-057-0160 Activities 1. Resident #1 & Resident #3 have had his / her individualized activity plan completd to the reflect the following: * Current abilities and skills * Emotional and social needs and patterns * Physical abilities and limitations; * Adaptations necessary for the resident to partcipate; and * Identification of activities for behavorial interventions. And Who, when, how and how often staff will offer and assist the residents to partcipate in group activities and / or assist with providing more individualized activites. 2.This system will be corrected so this violation does not happen again by ensuring that the individulized activity plans are updated with pre-scheduled (initial, 30-day and quarterly) and any acute or significant change of condition to reflect the residents current status per Oregon Administrative Rule. 3. The area needing correction will be evaluated at time of move-in, 30-day review, quarterly, and as needed if a change of condition occurs. 4. The Administrator, Activitiy Director or designee will be responsible to ensure corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to evaluate behavioral symptoms which negatively impacted the resident or others in the community and include them on the service plan for 1 of 2 sampled residents (#3) with documented behaviors. Findings include, but are not limited to: Resident 3 was admitted to the facility in 09/2022 with diagnoses including Alzheimer's disease. Resident 3's record documented behaviors including exit seeking, agitation, restlessness and aggression. Review of the record indicated Resident 3 exhibited exit seeking behaviors in which s/he would push against a heavy door to attempt to exit and the door would shut on his/her forearms, which resulted in bruising. Triggers for some of the behaviors included time of day and when spouse would leave the building after visiting Resident 3. There was no documented evidence the facility had completed a service plan which included an individualized behavior plan. On 06/08/23 at 11:25 am, the need to develop individualized behavior plans for residents with behavioral symptoms was discussed with Staff 1 (Executive Director), Staff 6 (Resident Services Coordinator), Staff 7 (Consultant) and Staff 8 (RN Consultant). They acknowledged the findings.

Z165 OAR  411-057-0160 (e) Behavior 1. Action taken to correct the rule violation is: Resident #3 will have an individualized behavior plan implemented to reflect his / her exit seeking, agitation, restlessness and aggression. 2.The system will be corrected so the violation will not happen again by ensuring all current memory care residents will be evaluated for behavioral symptoms, which negatively impact the resident or others. Based off this evaluation, resident specfic interventions to reduce, eliminate or de-escalate any identified behaviors that do negatively impact the resident or others will be identified and added to the service plan. 3. This area needing correction will be reviewed on a daily basis in stand-up upon review of 24- communication log and alert charting, and quarterly basis to ensure timely follow up is completed. 4. The Administrator, Licensed Nurse or designee will be responsible to ensure corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to ensure fencing surrounding the perimeter of the outdoor recreation area was no less than six feet in height and designed to prevent resident elopement. Findings include, but are not limited to: A tour of the outdoor recreation areas of the "West Memory Care Unit" on 06/07/23 revealed the fencing around the perimeter of the exterior patios was less than six feet in height in multiple areas due to uneven ground. The fence was loose and flexed several inches when pushed on. The outdoor recreation area was toured on 06/07/23 with Staff 1 (Executive Director) and Staff 4 (Maintenance Director). The need to ensure outdoor fencing was no less than six feet in height and designed to prevent resident elopement was discussed with Staff 1 and Staff 4. They acknowledged the findings.

Z173 OAR 411-057-0170 (6) Secure Outdoor Recreation Area 1. Action taken to correct this violation is Maintenance Director has bid's out for contractors to repair / replace the fencing around the perimeter of the exterior patios that are less then six feet in height and loose / flexed areas of the fencing. 2.The system will be corrected so this violation will not happen again by completing consistent environmental walk throughs to ensure fencing is six feet in height, with no loose or flex in the fence. 3.The area needing correction will be evaluated on a weekly and monthly basis with environmental audit to ensure timely follow up is completed. 4. The Administrator, Maintenance Director or designee will be responsible to ensure corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure their change of management survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 310 and C 530.

C-455 OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval Refer to C310 and C530

The findings of the re-licensure survey, conducted 06/06/23 through 06/08/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first revisit to the change of management survey of 06/08/23, conducted 01/02/24 through 01/04/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 57 for Memory Care Communities. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the second revisit to the re-licensure survey of 06/08/23, conducted 03/28/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and Community Based Services Regulations OARs 411 Division 004.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 03/30/2023.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Based on interview and observation it was confirmed that the facility failed to maintain equipment in good repair and failed to provide heating and ventilation systems capable of maintaining 70 degrees Fahrenheit. Findings include but not limited to: During an unannounced site visit on 07/29/2022 the Compliance Specialist (CS) interviewed Staff #1 (S1) and Staff 2 (S2) regarding the maintenance of equipment designed to keep the facility at a reasonable temperature. S1-3 and R1-3 stated the air conditioner has been out of order since 07/25/2022. CS and S1 used a facility thermometer to take the ambient room temperature of R1s room and it indicated 89 degrees Fahrenheit. CS observed the hall thermostat reading 87 degrees.  S1 stated that the facility is offering water, popsicles and personal fans to residents. CS observed a total of 18 cooling devices including three large portable AC units, 3 industrial sized fans throughout the facility, 2 turbo fans and several personal fans'. During an unannounced visit on 07/30/2022, the CS observed two commercially rented portable AC units at the facility. The CS observed S1 programming the units for blowing cool air into the facility. The CS observed large 12-inch hoses coming through the window and placed in the hallway to begin the process of cooling the facility. Facility Plan of Correction: Facility stated that bids are being reviewed to contract with a cooling maintenance company as soon as possible to ensure the heating and cooling equipment is operational and functioning properly.

Based on interview and observation it was confirmed that the facility failed to maintain equipment in good repair and failed to provide heating and ventilation systems capable of maintaining 70 degrees Fahrenheit. Findings include but not limited to: During an unannounced site visit on 07/29/2022 the Compliance Specialist (CS) interviewed Staff #1 (S1) and Staff 2 (S2) regarding the maintenance of equipment designed to keep the facility at a reasonable temperature. S1-3 and R1-3 stated the air conditioner has been out of order since 07/25/2022. CS and S1 used a facility thermometer to take the ambient room temperature of R1s room and it indicated 89 degrees Fahrenheit. CS observed the hall thermostat reading 87 degrees.  S1 stated that the facility is offering water, popsicles and personal fans to residents. CS observed a total of 18 cooling devices including three large portable AC units, 3 industrial sized fans throughout the facility, 2 turbo fans and several personal fans'. During an unannounced visit on 07/30/2022, the CS observed two commercially rented portable AC units at the facility. The CS observed S1 programming the units for blowing cool air into the facility. The CS observed large 12-inch hoses coming through the window and placed in the hallway to begin the process of cooling the facility. Facility Plan of Correction: Facility stated that bids are being reviewed to contract with a cooling maintenance company as soon as possible to ensure the heating and cooling equipment is operational and functioning properly.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 7/29/2022 and 7/30/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day