Barbur Vista Residential Care

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the main facility kitchen on 03/11/26, from 11:00 am through 12:40 pm, revealed the following deficient practices: 1. Main Kitchen: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and grease was visible on or underneath the following: * Folds of door seal gasket on small white refrigerator next to ware washing machine; * Trays under oven range; and * Bottom shelves of freezers in hallway closet. b. Items to be repaired or replaced: * Door seal gasket on small white refrigerator next to ware washing machine was torn; * Multiple large nonstick pans with majority of the nonstick surface worn away; * Multiple small wares with burn damage/uneven surfaces, rendering them unable to be cleaned and sanitized; and * Multiple small wares with worn wooden handles, rendering them unable to be cleaned and sanitized. 2. Procedures and Practices: c. Ground beef “chub” was thawing in the designated dish sink. d. No facial hair restraint in use. e. Multiple packaged food items in mini refrigerator without an open date. f. Prepared food item in mini refrigerator without a label or date. g. Handwashing sink hot water supply had been disconnected. h. Food preparation was occurring without a surface sanitation solution bucket set up. Surveyor addressed this with Staff 2 (Cook/Person in Charge) who then set up a surface sanitation solution bucket. Surface sanitation solution bucket was then later observed without a towel; towels were observed sitting on prep surfaces and being used multiple times without being returned to the sanitation bucket, potentially causing cross contamination. i. There were no testing strips available to test the parts per million (PPM) concentration of the surface sanitation solution being used, and therefore could not be validated that the solution being used was effectively sanitizing kitchen surfaces. j. Multiple packaged food items were in the standing reach-in cooler without an open date. k. Multiple prepared food items were in the standing reach-in cooler without an identifying label or production date. Kitchen staff disposed of these items. m. Kitchen staff were preparing “eggs to order” (over easy, sunny side up, etc.) without pasteurized eggs, resulting in undercooked eggs being served to residents. This surveyor instructed kitchen staff this practice could not continue until pasteurized eggs in shell were available for use. n. A digital probe thermometer was inserted into cooked food items without first sanitizing the probe. The thermometer was then put away without sanitizing. o. For dishes that did not fit in the mechanical warewashing machine that were being cleaned in the 3-compartment sink, there was not a final sanitizing step in the process. p. Corn tortillas were observed being served directly from the package without any fabrication/cooking/heating, resulting in the palatability of the food item being affected. q. Improper food thawing practices were observed. Staff had submerged frozen food in a water filled container that was sitting in a sink, but without a constant stream of cool water. r. An open can of soda (staff drink) without a lid/straw was observed above the area where food was being prepared. Staff 2 was unable to adequately articulate the following: s. Examples of situations that would result in cross-contamination occurring. t. The allowable timespan prepared food items could be in the culinary “danger zone.” u. The two-stage cooling process. v. The necessary cook-to temperature for reheating of food items. w. How to set up a station in the 3-compartment sink for sanitizing tools/pots/pans/hotel pans that don’t fit in the ware washing machine. x. Which chemical was being used for surface sanitation solution buckets. 2. Kitchenette in separate building: Procedure and Practices: a. Multiple food items were in the refrigerator without an open date (there was a sign posted on the refrigerator door instructing staff to label and date all refrigerated items). b. No testing strips were available for the ware washing machine, resulting in staff being unable to validate that the chemical PPM concentration was adequate for proper sanitizing. At approximately 12:45 pm, surveyor reviewed findings with Staff 1 (Business Manager) and Staff 2; Staff 1 and Staff 2 acknowledged the findings.

1.The facility immediately cleaned and sanitized all kitchen areas and equipment. Damaged items were removed and replaced. All unlabeled/undated food was discarded. Proper food handling practices were implemented, including correct thawing, labeling, sanitizer use, and thermometer sanitation. The handwashing sink was repaired. Staff drinks were removed from prep area. The facility discontinued the use of unpasteurized eggs for “eggs to order” and now only uses pasteurized or fully cooked eggs. A final sanitizing step using the three-compartment sink (wash, rinse, sanitize) was implemented for all dishes that do not fit in the commercial dishwasher. Sanitizer test strips were obtained and are now available and used in both the main kitchen and kitchenette areas. 2.A kitchen sanitation program was implemented including cleaning checklists, food labeling policies, and proper food handling procedures. Policies now require: • Use of pasteurized eggs or fully cooked eggs only • Proper three-compartment sink sanitizing procedures • Daily use of sanitizer test strips A kitchen binder has been implemented and staff were re-trained on all updated procedures. 3.Daily kitchen checks, weekly audits, and monthly reviews will be conducted. Monitoring includes: • Verification of egg compliance • Proper dishwashing and sanitizing procedures • Daily sanitizer test strip checks and documentation Any deficiencies will result in immediate corrective action and re-training. 4.Executive Director, Dietary Services Manager (DSM) Cook / Person in Charge

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable.

Based on observation and interview, it was determined the facility failed to ensure residents' right to have medical and other records kept confidential except otherwise provided by law for multiple unsampled residents. Findings include, but are not limited to: On 02/25/26 at 12:20 pm and 2:30 pm, three empty prescription bottles/boxes with labels including resident’s protected health information (PHI) were noted on top of an unattended medication cart in Cottage B. The same prescription bottles were noted on the same unattended medication cart on 02/26/26 at 9:00 am and 10:26 am. On 02/25/26 from 2:35 pm until 3:00 pm, the following was noted while observing Staff 6 (MT): * MT’s computer screen was left open and unattended with five residents and access to their PHI visible on the screen; * Medication administration records and empty medication cards with residents’ PHI were left unattended on the cart; and * Staff 3 (RCC) approached the unattended medication cart, retrieved an item, and left the medication administration records and empty medication cards on the cart. On 02/25/26 at 3:23 pm, a power of attorney form for an unsampled resident and PHI related to several residents’ diagnoses, diet, weight, and dates of birth was observed on an unsecured cabinet shelf in Cottage A’s dining room. From 02/24/26 through 02/27/26, PHI related to wounds and wound care was observed hanging on the exterior of an unsampled resident’s unit door. PHI related to diagnoses and allergies was also observed on a bulletin board by the exit to the balcony patio, in Cottage B. On 02/26/26 at 10:30 am, PHI related to hospice care for several residents was observed hanging on the bulletin board in the dining area in Cottage A. The need to ensure the residents' right to have medical and other records kept confidential except otherwise provided by law was discussed with Staff 1 (ED) on 02/25/26 at 1:10 pm and 02/26/26 at approximately 11:00 am. She acknowledged the findings.

1-All medication bottles and boxes with resident identifying information were immediately removed from public areas and disposed of according to facility policy to protect resident confidentiality. 2-A review of medication storage and disposal procedures was conducted with all staff. Staff were instructed that medication containers with resident information must never be left in common areas and must be disposed of in designated medication disposal containers. 3-Weekly Environmental checks will be conducted to ensure no resident information is visible or accessible in common areas. 4-Executive director and resident care coordinator

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable.

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 observation, interview, and record review, it was determined the facility failed to ensure a resident move-in evaluation addressed all required elements for 1 of 1 sampled resident (#3), and failed to ensure significant change of condition or quarterly evaluations were reflective of current care needs for 2 of 2 sampled residents (#s 1 and 2) whose most recent evaluations were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 2021. During the entrance conference on 02/24/26, staff reported the resident had a recent significant decline in health status and was currently receiving hospice services. Review of Resident 1’s clinical record, interviews with care staff, and observations of the resident during the survey revealed s/he was admitted to hospice on 02/12/26, received full assistance with all ADL care needs, and received bathing assistance from hospice staff. Resident 1's most recent evaluation, reviewed and signed by Staff 1 (ED) on 02/25/26, revealed it was not reflective of his/her needs in the following areas: * Bathing assistance; * Grooming assistance; * Transfer assistance and ambulation; * History of falls; * Continence status and assistance with toileting; * Eating and drinking assistance; * Ability to use call light; * Leaving facility with family for “lunch and coffee”; * Use of Warfarin (anticoagulant); * Use of pain medication; and * Hospice services. The need to ensure the evaluation was reflective of Resident 1's current care needs was discussed with Staff 1 (ED) during an interview on 02/25/26 at 12:10 pm. She acknowledged the findings. 2. Resident 2 was admitted to the facility on 04/2025 and had diagnoses which included Parkinson’s and Alzheimer’s dementia. Resident 2’s clinical record, interviews with care staff, and observations of the resident during the survey revealed s/he received assistance with ADL care needs in multiple areas and had a history of falls. Resident 2's most recent evaluation, dated 02/16/26, was not reflective of his/her needs in the following areas: * Side rail use: evaluation noted the resident used side rails when s/he did not; * Multiple falls; * Weight loss; * Nutritional supplement drink; and * Home health services. The need to ensure the evaluation was reflective of Resident 2's current care needs was discussed with Staff 1 (ED) during an interview on 02/26/26 at 1:55pm. She acknowledged the findings. 3. Resident 3 moved into the facility in 02/2026 with diagnoses including dementia without behavioral disturbance and Parkinson’s disease. The initial evaluation, dated 01/23/26, failed to address the following required elements: * Customary routines, including eating and bathing routines; * Visits to health practitioners, emergency room, hospital or nursing facility in the past year; * Personality, including how a person copes with change or challenging situations; * Activities of daily living, including transfer status; * Environmental factors that impact a resident’s behavior, including noise, lighting and room temperature; * Preferred name; * Pronouns; and * Gender identity. The need to ensure the initial evaluation addressed all required elements was discussed with Staff 1 (ED) on 02/25/26 at 1:15 pm. She acknowledged the findings.

1-The evaluations for the residents identified in the survey were immediately reviewed and updated to accurately reflect their current care needs and conditions. 2-All resident evaluations in the facility were reviewed to ensure: •Move-in evaluations contain all required elements •Quarterly evaluations are completed timely •Evaluations reflect the resident's current condition and care needs 3-ED will conduct monthly chart audits to ensure resident evaluations are completed and updated according to OAR requirements. 4-Executive Director and RN

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 and implemented for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 2021 with diagnoses which included high blood pressure and skin cancer. During the entrance conference on 02/24/26, staff reported the resident had a recent significant decline in health and was currently receiving hospice services. Review of Resident 1’s clinical record, interviews with care staff, and observations of the resident during the survey revealed s/he was admitted to hospice on 02/12/26, received full assistance with all ADL care needs, and received bathing assistance from hospice staff. Resident 1's current service plan, updated 02/12/26, was not reflective of the following areas: * Ability to use his/her call light to summon assistance; * Participation in activities; * Meal assistance; * Grooming assistance; * Sleeping preferences; and * Bathing assistance. The need to ensure the service plan was reflective of Resident 1's current needs was discussed with Staff 1 (ED) on 02/25/26 at 12:10 pm. Staff 1 acknowledged the service plan was not reflective in several areas and needed to be updated. No further information was provided. 2. Resident 2 was admitted to the facility on 04/2025 and had diagnoses which included Parkinson’s disease and Alzheimer’s dementia. Review of the resident’s clinical record, interviews with direct care staff, and observations of Resident 2 during the survey revealed s/he was incontinent, dependent on staff for most ADL care needs, had weight loss, drank a nutritional supplement, and had a history of falls. Resident 2's service plan dated 11/01/25, and a temporary service plan dated 12/12/25, was not reflective of the resident's needs or was not implemented in the following areas: * A temporary service plan instructed staff to “monitor meal intake and document percentage consumed.” Interviews with care staff during the survey revealed this was not being done; and * The service plan indicated the resident used a bed and chair alarm to alert staff when s/he “attempts to get up…” In an interview with Staff 1 (ED) on 02/26/26 at 1:55 pm, she stated the resident no longer used the alarms. The need to ensure the service plan was reflective of Resident 2's current care needs and was implemented was discussed with Staff 1 (ED) during an interview on 02/26/26 at 1:55pm. She acknowledged the findings.

1-Service plans for the residents reviewed during the survey were updated to reflect their current care needs. 2-All resident service plans were reviewed to ensure: •Service plans are updated quarterly •Changes are dated and initialed •Historical information is maintained 3-Will do Monthly chart audits to verify service plans are updated and compliant 4- Executive Director , RCC and RN

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 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift.

Based on interview and record review, it was determined the facility failed to monitor a resident consistent with evaluated needs and service plan for 1 of 1 sampled resident (#2) who experienced short-term changes of condition related to multiple falls. Findings include, but are not limited to: Resident 2 was admitted in 04/2025 with diagnoses including Parkinson’s disease, Alzheimer’s dementia, and had a history of falls. Resident 2's clinical record, service plan, temporary service plans, incident reports, and charting notes reviewed from 12/02/25 through 02/20/26, revealed the following: Resident 2 fell five times between 12/02/25 and 02/14/26. There was no documented evidence the facility consistently monitored fall interventions identified on the service plan or temporary service plans for implementation and effectiveness consistent with the resident’s evaluated needs and service plan. The need to ensure the facility monitored fall interventions consistent with evaluated needs and service plan was discussed with Staff 1 (ED) on 02/27/26 at 8:15 am. She acknowledged the findings.

1-Resident records were reviewed and documentation was corrected to ensure care plans and evaluations accurately reflect resident needs. 2-The facility implemented a documentation review process to ensure: •Resident condition changes are documented promptly •Care plans are updated accordingly •Staff communicate changes in resident status. 3-Executive Director will conduct monthly documentation audits. 4-Executive Director

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift.

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

A. Based on interview and record review, it was determined the facility failed to ensure significant change of condition assessments, which included documented findings, resident status and interventions made as a result of the assessment, were completed or completed timely by a facility RN, and that the licensed nurse participated on the service planning team or reviewed the service plan within 48 hours, for 2 of 2 sampled residents (#s 1 and 2) reviewed for significant changes of condition. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 2021 with diagnoses which included high blood pressure and skin cancer. During the entrance conference on 02/24/26, staff reported the resident had a recent significant decline in health and was currently receiving hospice services. Review of Resident 1’s clinical record revealed the following: * S/he had a significant decline in health status and was admitted to hospice on 02/12/26. The decline in health and admission to hospice constituted a significant change in condition for which a timely RN assessment which included documented findings, resident status and interventions made as a result of the assessment was required, and that the licensed nurse participated on the service planning team or reviewed the service plan within 48 hours; * There was no documented evidence the facility RN conducted an assessment until 02/24/26 (completed during survey); and * There was no documented evidence the licensed nurse participated on the service planning team or reviewed the service plan within 48 hours. During an interview on 02/25/26 at 12:10 pm, Staff 1 (ED) reviewed the record and acknowledged the RN assessment had not been completed timely, nor had the licensed nurse participated on the service planning team or reviewed it within 48 hours. She added that Staff 2 (RN) was on vacation during that period, and Staff 1 failed to notify the on-call RN to come in, assess the resident, and review the plan of care. The need to ensure RN assessments were completed timely by a facility RN, and that the licensed nurse participated on the service planning team or reviewed the service plan within 48 hours was reviewed during the exit conference on 02/27/26 with Staff 1 (ED) and Staff 2 (RN). The findings were acknowledged. 2. Resident 2 was admitted in 04/2025 with diagnoses including Parkinson’s and Alzheimer’s dementia. During the entrance conference on 02/24/26, staff reported the resident had a recent significant overall decline in health related to weight loss. The clinical record, from 12/2025 through 02/24/26, was reviewed during the survey and revealed the following: * Weight records indicated the resident’s weights as follows: - 08/2025: 196.8 lbs; - 09/2025: 196 lbs; - 10/2025: 195.9 lbs; - 11/2025: no weight recorded; - 12/12/25: 180.2 lbs. (15.7 lb. loss); - 01/27/26: 176 lbs. (4.2 lb. loss); and - 02/26/26 (weight obtained during survey) 174 lbs. (2 lb. loss). * Between 10/2025 and 12/12/25, the resident lost 15.7 pounds, or 8% of his/her total body weight, in two months. This constituted a severe loss and a significant change in condition that required an RN assessment, which included documented findings, resident status, and interventions made as a result of the assessment, in addition to a licensed nurse participating on the service planning team or reviewing the service plan with date and signature within 48 hours. Although Staff 3 (RCC) initiated a temporary service plan on 12/12/25, there was no evidence the facility RN performed an assessment of the resident’s severe weight loss or that a licensed nurse participated on the service planning team or reviewed the service plan within 48 hours. Additional information was requested on 02/27/26. The resident was observed in the dining room during the noon meal on 02/24/26. Staff provided intermittent cueing and meal assistance, and s/he consumed approximately 75%. During an interview on 02/27/26 at 8:15 am, Staff 1 (ED) reviewed the record and acknowledged the lack of an RN assessment which included documentation of findings, the resident's status, and interventions made as a result of the assessment for the significant change in condition, and the lack of documented evidence a licensed nurse participated on the service planning team or reviewed the service plan within 48 hours. Staff 2 (RN) was interviewed via telephone on 02/27/26 at 9:35 am. She stated she worked “limited hours” and that an RN assessment had not been completed because the facility did not inform her of the weight loss. The need to ensure significant change of condition assessments, which included documented findings, resident status, and interventions made as a result of the assessment, were completed by an RN, and that the licensed nurse participated on the service planning team or reviewed the service plan within 48 hours was reviewed with Staff 1 (ED) and Staff 2 (RN) during the exit conference on 02/27/26. The findings were acknowledged. B. Based on interview and record review, it was determined the facility failed to ensure regularly scheduled licensed nursing for onsite duties and failed to ensure an adequate number of nursing hours relevant to the acuity of the resident population. Findings include, but are not limited to: During the survey, the facility was home to 26 residents. The entrance conference acuity interview was conducted with Staff 1 (ED) and Staff 5 (MT) on 02/24/26. During the interview, Staff 1 and 5 identified 17 residents with heavy care needs. Review of the posted staffing plan indicated “Registered Nurse visits for 10-16 hours per week.” During an interview with Staff 1 on 02/26/26 at 9:40 am, she stated Staff 2 (RN) “usually comes in on the weekends” but was not sure exactly what hours she worked. The surveyor requested documentation of licensed nurse hours worked for the past three months. On 02/26/26, Staff 1 provided Staff 2’s days and hours worked from 11/25/25 through 02/25/26. According to the documentation, Staff 2 worked the following days/hours: * 11/25/25: two hours; * 12/03/25: one hour; * 01/20/26: one hour; * 01/23/26: two hours; * 01/24/26: one hour; and * 02/25/26: one hour. From 11/25/25 through 02/25/26, the facility RN worked eight hours. In an interview on 02/26/26 at 2:00 pm, the discrepancy between posted RN hours and actual hours worked was reviewed. Staff 1 said, “I thought she was coming in on the weekends and staying the entire day. I know I need more RN hours. We have high acuity in the facility, and I need help with that . . .” Staff 1 acknowledged the RN was not regularly scheduled for onsite duties nor had the facility ensured an adequate number of nursing hours relevant to the acuity of the resident population. The need to ensure regularly scheduled licensed nursing hours for onsite duties and an adequate number of nursing hours relevant to the acuity of the resident population was reviewed with Staff 1 (ED) and Staff 2 (RN) during the exit conference on 02/27/26. The findings were acknowledged.

1-The resident health service documentation identified during the survey was immediately reviewed and updated to ensure it accurately reflects the resident’s health status,needs,and services being provided. 2-The facility reviewed health service procedures to ensure resident health information, physician orders, and care needs are properly documented and communicated among staff. •Established a regular RN schedule of a minimum of (16–24)hours per week,adjusted based on resident acuity. •Implemented an on-call RN system to ensure coverage at all times. •Implemented a policy requiring immediate RN notification for any significant change in condition. •RN will complete assessments and review/sign service plans within 48 hours of significant change. •Implemented a tracking log for RN hours, assessments, and service plan reviews. 3-Monthly resident chart audits for three months to ensure health services documentation is complete and current. 4-Executive Director ,RN and RCC

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

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

A. Based on interview and record review, it was determined the facility failed to ensure significant change of condition assessments, which included documented findings, resident status and interventions made as a result of the assessment, were completed by a facility RN, and that the licensed nurse participated on the service planning team or reviewed the service plan within 48 hours, for 1 of 1 sampled resident (#5) reviewed for a significant change of condition. This is a repeat citation. Findings include, but are not limited to: Resident 5 was admitted to the facility in 2024 with diagnoses which included coronary artery disease and urine retention. During the entrance conference on 05/11/26, staff reported the resident had a recent significant decline in health related to a left ankle fracture and increased assistance in care needs, including and the use of a Hoyer lift and two staff for all transfers. Review of Resident 5’s clinical record revealed the following: * Resident 5 was sent to the hospital on 05/04/26 following a recent fall. S/he returned to the facility on 05/06/26 with the diagnosis of a closed left ankle fracture. The fracture and increased ADL care needs constituted a significant change in condition for which an RN assessment which included documented findings, resident status and interventions made as a result of the assessment was required, and that the licensed nurse participated on the service planning team or reviewed the service plan within 48 hours. * Although Staff 3 (RCC) initiated temporary service plans on 05/06/26 related to the fracture and change in ADL care needs, and evaluated the resident and updated the service plan on 05/07/26, there was no evidence the facility RN performed an assessment of the resident’s significant change in condition or that a licensed nurse participated on the service planning team or reviewed the service plan within 48 hours. Additional information was requested on 05/11/26. During an interview on 05/11/26 at 11:35 am, Staff 1 (ED) reviewed the record and was unable to find documentation that an RN assessment had been completed and that the licensed nurse participated on the service planning team or reviewed it within 48 hours. Staff 2 (RN) was unavailable for interview during the revisit survey. The need to ensure RN assessments were completed timely by a facility RN, and that the licensed nurse participated on the service planning team or reviewed the service plan within 48 hours was reviewed during the exit conference on 05/12/26 with Staff 1 (ED). The findings were acknowledged. B. Based on interview and record review, it was determined the facility failed to ensure regularly scheduled licensed nursing for onsite duties and failed to ensure an adequate number of nursing hours relevant to the acuity of the resident population. This is a repeat citation. Findings include, but are not limited to: During the revisit survey, the facility was home to 24 residents. The entrance conference acuity interview was conducted on 05/11/26 with Staff 5 (MT). During the interview, Staff 5 identified multiple residents with heavy care needs. Review of the posted staffing plan indicated “Registered Nurse visits for 16-24 hours per week.” On 05/11/26, the surveyor requested documentation of licensed nurse hours worked from 03/01/26 to 05/10/26. In an interview with Staff 1 on 05/11/26 at 12:00 pm, she stated she was unsure what days or hours Staff 2 (RN) had worked during that time frame. She said she would contact Staff 2. On 05/12/26, Staff 1 said that between 03/01/26 and 05/10/26, Staff 2 worked on one day, 03/13/26. Staff 1 was unsure how many hours Staff 2 worked that day. From 03/01/26 through 05/10/26, the facility RN worked on one day. In an interview with Staff 1 on 05/12/26 at 9:35 am, the discrepancy between posted RN hours and actual hours worked was reviewed. Staff 1 said the facility had just hired another RN that would be starting soon. The need to ensure regularly scheduled licensed nursing hours for onsite duties and an adequate number of nursing hours relevant to the acuity of the resident population was reviewed with Staff 1 (ED) during the exit conference on 05/12/26. The findings were acknowledged.

1. Corrective action for resident/example: Resident #5 was immediately reviewed for significant change of condition related to the left ankle fracture, increased ADL needs, Hoyer lift use, and two-person transfer needs. The facility RN completed/updated the RN significant change assessment, documented resident status, findings, interventions, transfer needs, fall risk/safety measures, pain/skin monitoring, and follow-up needs. The service plan was reviewed/updated to include Hoyer lift transfer with two staff, mobility limitations, toileting/ADL assistance, monitoring for pain/skin integrity, and notification requirements. The RN reviewed/signed the updated service plan. ED/RCC confirmed staff were informed of the updated care needs before providing care. 2. System correction to prevent recurrence: The facility implemented a Significant Change/RN Assessment Tracking System. Any hospital return, fracture, fall with injury, new Hoyer lift/two-person transfer need, hospice admission, pressure injury, uncontrolled pain, acute health change, or major ADL decline will trigger same-day notification to ED/RCC and RN. The ED/RCC will place the resident on the RN Assessment Log and notify the RN immediately. The RN will complete and document an assessment timely and will participate in the service planning team or review/sign the updated service plan within 48 hours when a significant change service plan is completed. ED/RCC will audit the log before the end of each business day. Staff were re-educated on what constitutes a significant change and the requirement to notify ED/RCC/RN immediately. A licensed nurse schedule/log was also implemented to verify regular onsite RN duties and adequate RN hours based on census and acuity. The posted staffing plan will match actual RN coverage. 3. Evaluation frequency: ED/RCC will review the Significant Change/RN Assessment Log daily for 30 days, then weekly for 3 months, then monthly as part of QAPI. RN hours and onsite visit documentation will be reviewed weekly for 3 months and monthly thereafter. Any missed RN assessment, missing RN service plan review, or RN-hour discrepancy will be corrected immediately and documented. 4. Responsible person: Executive Director is responsible for overall compliance. RCC is responsible for daily tracking, staff notification, and service plan follow-up. Facility RN is responsible for completing/documenting RN assessments and reviewing/signing service plans within required timeframes. ED will monitor completion and maintain evidence in the survey-ready binder.

OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(B) Delegation and Teaching. Delegation and teaching must be provided and documented by a RN in accordance with the Oregon Administrative Rules adopted by the Oregon State Board of Nursing in chapter 851, division 047.

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (#4) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to: According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task, and observing the staff demonstrate the task. During the acuity interview on 02/24/26, Resident 4 was identified to be administered insulin injections by non-licensed staff. Resident 4’s MARs, reviewed from 02/01/26 through 02/25/26, revealed the resident received insulin (to treat diabetes) four times a day. The insulin had been given by Staff 4, Staff 5, and Staff 6 (all MTs) on multiple occasions. Review of initial delegation records for Staff 4 (delegated on 10/28/25), Staff 5 (delegated on 10/31/25), and Staff 6 (delegated on 11/28/25) revealed the following: a. There was no documentation by the RN verifying that all requirements from the initial delegation were met. b. There was no documentation the RN addressed questions the resident may have had. c. There was no documented evidence the RN evaluated the frequency the resident should be reassessed based on their assessed baseline and health problems that may impact the resident’s condition related to the delegated nursing procedure, whether the RN previously authorized the same MTs for the same procedure, and the length of time the RN had worked with the MTs. d. The initial delegation for Staff 6 was completed on 11/28/25. The last delegation assessment completed by the RN was on 10/25/25. There was no evidence the RN performed an assessment of the resident at the time Staff 6 was delegated. Review of periodic inspection records for Staff 4 (completed on 01/24/26), Staff 5 (completed on 01/22/26), and Staff 6 (completed on 02/25/26) reveled the following: a. There was no documentation by the RN verifying that all requirements from the delegation were met. b. There was no assessment of the resident. The requirements for delegation were reviewed with Staff 2 (RN) during interviews on 02/27/26. She acknowledged the findings. The need to ensure all staff who administered insulin injections were appropriately delegated in accordance with OSBN Administrative Rules was discussed with Staff 1 (ED) and Staff 2 (RN) during the exit conference on 02/27/26. They acknowledged the findings.

1.The RN reviewed and corrected all delegation records for Staff 4, 5, and 6 to ensure compliance, including required documentation. Resident #4 was reassessed, and a current nursing assessment was completed. Staff were re-trained, and competency was verified through return demonstrations. A reassessment schedule was established. Delegation for Staff 6 was completed following a current assessment. All periodic inspections were updated with proper documentation. 2.A standardized RN delegation process, checklist, and tracking log have been implemented to ensure all required steps are completed and documented. 3.Monthly audits for three months, then quarterly. 4.Executive Director and RN

OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(B) Delegation and Teaching. Delegation and teaching must be provided and documented by a RN in accordance with the Oregon Administrative Rules adopted by the Oregon State Board of Nursing in chapter 851, division 047.

OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(B) Delegation and Teaching. Delegation and teaching must be provided and documented by a RN in accordance with the Oregon Administrative Rules adopted by the Oregon State Board of Nursing in chapter 851, division 047.

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (#4) who received insulin injections by unlicensed facility staff. This is a repeat citation. Findings include, but are not limited to: According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task, and observing the staff demonstrate the task. During the acuity interview on 05/11/26, Resident 4 was identified to be administered insulin injections by non-licensed staff. Resident 4’s MARs, reviewed from 05/01/26 through 05/10/26, revealed the resident received insulin (to treat diabetes) four times a day. The insulin had been given by Staff 7 (MT) on multiple occasions. Review of delegation records for Staff 7 revealed the following: *The initial delegation was completed by Staff 2 (RN) on 11/03/25. Per the delegation documentation, it expired on 03/01/26; and *According to the OSBN delegation rules, periodic inspection and evaluation must occur prior to the end of the initial authorization period. As of the survey on 05/11/26, no periodic inspection and evaluation had been completed. Staff 2 was not present at the facility during the revisit. During an interview with Staff 1 (ED) on 05/11/26 at 1:55 pm, she reviewed the record and was unable to find periodic inspection and evaluation delegation documentation for Staff 7. The need to ensure all staff who administered insulin injections were appropriately delegated in accordance with OSBN Administrative Rules was discussed with Staff 1 (ED). She acknowledged the findings. On 05/12/26, Staff 1 stated that Staff 2 came in last evening and completed the delegation for Staff 7. A copy of the delegation was given to the surveyor.

1. Corrective action for resident/example: Resident #4’s insulin delegation record for Staff #7 was reviewed. Staff #7’s prior delegation had expired on 03/01/26 and the RN completed updated delegation documentation on 05/12/26. Before any unlicensed staff administer insulin or other special tasks of nursing care, the facility will verify that written RN delegation is current, resident-specific, task-specific, and staff-specific. If delegation is expired or missing, the staff member will not perform the delegated task until the RN completes assessment, teaching, return demonstration/competency validation, written authorization, and required supervision/evaluation. 2. System correction to prevent recurrence: The facility implemented a Delegation Tracking Binder and Delegation Expiration Log for all delegated nursing tasks, including insulin administration. The log will include resident name/identifier, delegated task, staff name, RN name, date delegated, expiration/review date, competency/return demonstration date, and periodic inspection/evaluation due date. ED/RCC will review the log before scheduling staff to perform delegated tasks. Medication technicians and caregivers will be re-educated that they may not perform insulin injections or other special nursing tasks unless current written RN delegation is on file. The RN will complete all delegation, teaching, competency evaluation, return demonstration, and periodic inspection/evaluation according to OSBN Division 47 requirements. A reminder system will be used 30 days before expiration so periodic inspection/evaluation is completed before the delegation expires. 3. Evaluation frequency: ED/RCC will audit the Delegation Expiration Log weekly for 3 months, then monthly as part of QAPI. The RN will review active delegations at least monthly and before any delegation expiration date. Any expired, incomplete, or missing delegation will result in immediate removal of the staff member from that task until RN delegation is completed. 4. Responsible person: Facility RN is responsible for delegation, teaching, competency validation, and periodic inspection/evaluation. RCC is responsible for maintaining the delegation binder/log and checking delegation status before assigning tasks. Executive Director is responsible for monitoring the system and ensuring corrective action is completed.

OAR 411-054-0055 (1)(b-d) Systems: Medication Administration (b) Medications administered by the facility must be set-up or poured and documented by the same person who administers the medications.(c) The staff person who administers the medication must visually observe the resident take (e.g., ingest, inhale, apply) the medication unless the prescriber's order for that specific medication states otherwise.(d) Medications must be kept secure between set-up and administration of medications.

Based on observation and interview, it was determined the facility failed to ensure medications were kept secure between set-up and administration of medications for multiple unsampled residents. Findings include, but are not limited to: On 02/25/26 at 12:20 pm, there were several medications found in an unlocked cupboard and refrigerator in Cottage B. The need to ensure medications were kept secure between set-up and administration of medications was discussed with Staff 1 (ED) on 02/25/26 at 1:10 pm. She acknowledged the findings.

1-The medication administration practices identified during the survey were immediately reviewed. Any discrepancies in medication administration or documentation were corrected to ensure medications are administered and documented according to physician orders and facility policy. 2-The facility reviewed its medication administration procedures to ensure medications are: •Administered according to physician orders •Documented accurately on the Medication Administration Record (MAR) •Stored and handled according to facility policy and safety requirements All resident MARs were reviewed to verify accuracy and compliance. 3-Weekly MAR Audits 4- Executive Director, RCC, RN

OAR 411-054-0055 (1)(b-d) Systems: Medication Administration (b) Medications administered by the facility must be set-up or poured and documented by the same person who administers the medications.(c) The staff person who administers the medication must visually observe the resident take (e.g., ingest, inhale, apply) the medication unless the prescriber's order for that specific medication states otherwise.(d) Medications must be kept secure between set-up and administration of medications.

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

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 sampled direct care staff (#s 6, 7, 8, and 9) demonstrated satisfactory performance in any duty they were assigned within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed with Staff 1 (ED) on 02/26/26 at 10:33 am. There was no documented evidence Staff 6 (MT), hired on 11/10/25, Staff 7 (MT), hired on 11/03/25, Staff 8 (CG), hired on 11/22/25, and Staff 9 (CG), hired on 01/06/26, had demonstrated competency in one or more of the following areas: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting changes of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety and sanitation; and * First Aid/Abdominal Thrust. The need to ensure newly hired direct care staff had demonstrated satisfactory performance in all required areas within 30 days of hire was reviewed with Staff 1 (ED) on 02/26/26 at 10:33 am. She acknowledged the findings.

1-The staff training records identified during the survey were immediately reviewed. Any staff member whose required training was incomplete or not documented within the required timeframe had the training completed and documentation updated in the employee file. 2-All employee files were reviewed to ensure required orientation and training are completed within 30 days of hire in accordance with state requirements. A tracking system has been implemented to monitor staff training deadlines and ensure all required training is completed timely. 3-Review employee training records monthly for three months to ensure all new staff complete required training within the required timeframe. Ongoing monitoring will continue during routine personnel file audits. 4- Executive director and Office Manager

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

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 interview and observation, it was determined the facility failed to ensure the grounds were kept orderly and free of litter and refuse, were free from drop-offs, and locked storage was provided for all toxic materials. Findings include, but are not limited to: The facility was toured with Staff 1 (ED) on 02/25/26 at 1:10 pm. The following was noted: * On 02/24/26 at 10:45 am, Oxivir TB disinfectant and Windex cleaner were noted to be unsecured in the common restroom of Cottage A. * On 02/25/26 at 10:03 am, a bottle of bleach was noted in an unsecured cupboard in the laundry room of Cottage B and multiple spray bottles filled with various toxic chemicals were noted in the laundry room of Cottage A. * On 02/25/26 at approximately 12:40 pm, there was refuse noted along the back corner patio and upper portion of the pathway on the side of Cottage B. * On 02/24/26, drop-offs exceeding one inch were noted along the exterior pathways of both Cottages A and B. The need to ensure the grounds were kept orderly and free of litter and refuse, were free from drop-offs that exceeded one inch, and there was locked storage for all toxic materials was discussed with Staff 1 (ED) on 02/25/26 at 1:10 pm. She acknowledged the findings.

1-The exterior condition identified during the survey was immediately addressed. The area noted by the surveyor was inspected and repairs or cleaning were completed to ensure the exterior of the building is safe, well maintained, and free from hazards. 2-The facility conducted a full inspection of the building exterior, including walkways, entrances, outdoor areas, and surrounding grounds, to ensure all areas are maintained in a safe and clean condition. Any maintenance needs identified during this inspection were corrected. 3-Monthly Exterior safety inspection 4- Executive Director and Maintenance

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 lever-type handles were provided on all doors used by residents and the facility was kept clean and in good repair and was free from unpleasant odors. Findings include, but are not limited to: The facility was toured with Staff 1 (ED) on 02/25/26 at 1:10 pm. The following was noted: * The lever-type door handle on the entrance to Cottage B was not functioning properly and several door handles in Cottage B were in disrepair; * Scuffs, chipped paint, and gouges were noted on doors, door frames, furniture, cupboards, and handrails throughout both Cottages A and B, making some surfaces uncleanable. The door seal around apartments 7, 9, and 14 was loose; * An unpleasant and pervasive odor was noted throughout the survey in the upper level and staircase in Cottage B; * There was debris and dust noted on baseboards and windowsills throughout Cottages A and B and on the ventilation screen near the main sink on the lower level of Cottage B; * Furniture throughout the interior and exterior of both Cottages A and B was dirty, stained, moldy, or in disrepair; * Food and fluid drips were noted on cupboards, microwave, and refrigerator in the kitchenette of Cottage B; and * The tile flooring in the kitchenette in Cottage B was cracked in places, creating an uncleanable surface. The need to ensure that lever-type handles were provided on all doors used by residents and the facility was kept clean, in good repair, and free from unpleasant odors was discussed with Staff 1 (ED) on 02/25/26 at 1:10 pm. She acknowledged the findings.

1-The areas identified during the survey were inspected and corrected. Doors, walls, and interior areas were cleaned and repaired as needed, and any odors identified were addressed through cleaning and ventilation to ensure a clean and comfortable environment for residents 2-The facility reviewed housekeeping and maintenance procedures to ensure the interior of the building is maintained in a clean, sanitary, and odor-free condition. Routine cleaning and maintenance schedules were reinforced to ensure doors, walls, and common areas are regularly inspected and maintained. 3-Weekly Environmental rounds and followed by monthly inspections 4-Executive Director and Maintenance

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 (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 lever-type handles were provided on all doors used by residents and the facility was kept clean and in good repair and was free from unpleasant odors. This is a repeat citation. Findings include, but are not limited to: The facility was toured with Staff 1 (ED) on 05/12/26 at 9:00 am. The following was noted: * The lever-type door handle on the entrance to Cottage B was not functioning properly; * Pervasive odor was noted throughout the survey in the upper level in Cottage B; * There was debris and dust noted on some baseboards and windowsills throughout Cottage B; * Food and fluid drips were noted on cupboards, the microwave, and refrigerator in the kitchenette of Cottage B; and * The tile flooring in the kitchenette in Cottage B was cracked in places, creating an uncleanable surface. The need to ensure that lever-type handles were provided on all doors used by residents and the facility was kept clean, in good repair, and free from odors was discussed with Staff 1 (ED) on 05/12/26 at 9:00 am during the environment walk through, and again at 11:30 am. She acknowledged the findings.

1. Corrective action for resident/example: Cottage B entrance lever-type door handle was inspected and repaired/replaced to ensure it functions properly for resident use. Cottage B was deep cleaned, including baseboards, windowsills, cupboards, microwave, refrigerator, and kitchenette surfaces. The upper-level odor concern was addressed through immediate cleaning, trash/soiled-linen removal, carpet/floor cleaning as applicable, ventilation, and review for possible source of odor. The cracked kitchenette tile flooring was evaluated and repaired/replaced or covered with an approved cleanable repair until permanent repair is completed, to maintain a cleanable surface. 2. System correction to prevent recurrence: The facility implemented a Cottage B Environmental Rounds Log and Cleaning/Maintenance Tracking System. Housekeeping staff will complete daily cleaning of high-touch and food-service areas, including the kitchenette, microwave, refrigerator exterior/interior as assigned, cupboards, baseboards, and windowsills. Staff will report odors, broken handles, cracked flooring, or uncleanable surfaces immediately to ED/RCC or maintenance. Maintenance will complete weekly environmental rounds for door hardware, flooring, walls, ceilings, furniture, odors, and repair needs. ED/RCC will verify that resident-use doors have functioning lever handles and that interior/exterior surfaces remain clean, odor-free, and in good repair. Staff were re-educated on reporting environmental concerns immediately and documenting completion of cleaning/maintenance tasks. 3. Evaluation frequency: Housekeeping/odor checks will be completed daily for 30 days, then weekly. Maintenance rounds will be completed weekly for 3 months, then monthly. ED/RCC will audit Cottage B weekly for 3 months and monthly through QAPI. Any odor, cleanliness concern, broken lever handle, or damaged flooring will be corrected promptly and documented on the maintenance log. 4. Responsible person: Executive Director is responsible for overall environmental compliance. Maintenance/designee is responsible for repairs, door hardware, flooring, and maintenance rounds. Housekeeping Lead/designee is responsible for daily cleaning and odor control. RCC/ED will monitor completion of logs and verify sustained correction.

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, it was determined the facility failed to ensure initial evaluations addressed all required elements, including the preferred name, pronouns, and gender identity for 1 of 1 sampled resident (#3) whose 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 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation.

Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to: Refer to C0280, C0282, and C0513.

1. Corrective action for resident/example: The facility reviewed the revisit findings related to the prior relicensure plan of correction and identified areas requiring stronger implementation: RN significant change assessments/service plan review (C280), RN delegation/teaching supervision (C282), and environmental cleanliness/repair/odor control (C513). Immediate corrective actions were initiated for each cited area, including RN assessment/service plan tracking, delegation tracking, and Cottage B environmental repair/cleaning/odor remediation. 2. System correction to prevent recurrence: The facility implemented a POC Compliance Monitoring Binder to track each citation, action item, responsible person, completion date, proof of completion, and ongoing audit results. The ED will conduct a weekly POC review meeting with RCC, RN, maintenance/housekeeping lead, and/or designee until sustained compliance is demonstrated. Each prior POC item will remain on the tracking log until evidence shows implementation is complete and ongoing monitoring is occurring. The ED will verify that policies, logs, staff education, RN documentation, delegation records, and environmental repairs match the plan of correction and are available for review. 3. Evaluation frequency: POC items will be evaluated weekly through 06/26/26 and weekly for 3 additional months, then monthly during QAPI. Any item found incomplete will be corrected immediately, assigned to a responsible person, and rechecked within 24-72 hours depending on the issue. 4. Responsible person: Executive Director is responsible for ensuring the POC is implemented, monitored, and sustained. RCC, Facility RN, and Maintenance/Housekeeping Lead are responsible for completing and documenting assigned corrective actions. ED will maintain the compliance binder and report progress through QAPI.

Based on observation and interview, it was determined the facility failed to ensure a resident's right to receive services in a manner that protected privacy and dignity for 1 of 1 unsampled resident who received ADL care. Findings include, but are not limited to: An observation conducted at 12:12 pm on 03/26/24 revealed the following: Staff 9 (CG) entered Room 1 and stated to the unsampled resident that it was time to go to lunch. Staff 9 then stated, "You're wet. I need to change you." He proceeded to provide incontinent care for the unsampled resident while the door to the resident's room was open and the care provided was in view of the hallway. The need to ensure residents had the right to receive services in a manner that protected privacy and dignity was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 03/27/24. They acknowledged the findings.

1. All staff training will be conducted on 4/4/2024 to re-educate staff regarding resident rights and to ensure services are provided in a manner that protects privacy and dignity. 2. The resident care coordinator and executive director will conduct weekly observation checks with staff while providing care to residents. 3. Weekly 4. Resident Care Coordinator and Executive Director

Based on observation, interview, and record review, it was determined the facility failed to ensure resident service plans were reflective of resident needs, were readily available to staff, and provided clear direction to staff regarding the delivery of services for 3 of 4 sampled residents (#s 1, 2, and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 01/2024 with diagnoses that included ataxic gait and chronic pain.   The service plan available to staff was dated 01/09/24. Resident 4 was out of the facility between 01/20/24 and 3/11/24. The resident returned to the facility with several changes including: * Smoker; * Fall risk; * Safety checks two times per shift; * Pain in right shoulder, neck; and * Non-pharmalogical interventions for pain: rest, ice pack, PRN medication. A review of the resident's clinical record showed the most current service plan was dated 03/11/24. The service plan was not available to direct care staff for review. The need to ensure service plans were available to care staff was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (Resident Care Director) on 03/27/24. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 10/2023 with diagnoses including Parkinson's Disease. The resident's current service plan dated 01/25/24 and temporary service plans were reviewed, interviews were conducted, and observations were made. The service plan was not reflective of the resident's needs and preferences in the following areas: * Supportive devices including use of four-wheeled walker and wheelchair; * Ambulation status; * Transfer status; * Evacuation assistance; * Activities; * Use of glasses/vision status; * Grooming assistance; and * Toileting assistance. The need to ensure service plans were reflective of residents' needs and preferences was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 03/27/24. They acknowledged the findings. 3. Resident 1 was admitted to the facility in 08/2023 with diagnoses including Lewy body dementia. The resident's current service plan dated 02/23/24 and temporary service plans were reviewed, interviews were conducted, and observations were made. The service plan was not reflective of the resident's needs and preferences in the following areas: * Communication status; * Fall history; and * Use of a catheter. The need to ensure service plans reflected residents' needs and preferences was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 03/27/24. They acknowledged the findings.

1. All service plans will be made available to care staff when a resident experiences a change in condition. 2. All service plans will be reviewed and updated to reflect the resident's care needs. 3. All service plans will be reviewed for accuracy by 5/31/2024 and will continue to be reviewed on a monthly basis. 4. Resident Care Coordinator and Executive Director

Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment for multiple sampled and unsampled residents during ADL care and meal service. Findings include, but are not limited to: Observations made from 03/25/24 to 03/26/24 revealed the following: 1. Observations of lunch service on 03/25/24 and 03/26/24 revealed multiple universal caregivers served food and provided direct feeding to residents without donning a protective barrier over potentially contaminated clothing. 2. Staff 9 (CG) and Staff 15 (CG) were observed at 12:00 pm on 03/26/24. Staff 15 entered Room 8 wearing single use gloves, assisted the resident with transferring, then exited the room. She did not remove the gloves or perform hand hygiene after leaving the room. Staff 9 and Staff 15 entered Room 4 wearing single use gloves and assisted the resident with repositioning in bed. They exited the room, doffed the single use gloves, and donned clean gloves without performing hand hygiene. They both began serving residents and carrying food from the kitchen pass to dining room tables. 3. Staff 9 was observed providing incontinent care to an unsampled resident at 12:12 pm on 03/26/24. He entered the room wearing single use gloves and began assisting the resident with a brief change. He changed the soiled briefs and pants, then donned cleaned briefs and pants without removing soiled gloves and performing hand hygiene first. He then exited the room wearing the soiled gloves, removed them in the dining room, and donned new gloves without performing hand hygiene. He then began serving food to residents in the dining room. 4. Staff 11 (CG) was observed walking out of a resident's room with incontinent trash at 12:39 pm on 03/26/24. She disposed of the trash, doffed soiled gloves, and walked into another resident's room without performing hand hygiene. The need to establish and maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 03/27/24. They acknowledged the findings.

1. All staff training will be conducted on 4/4/2024 regarding infection prevention and control to ensure a safe, sanitary, and comfortable environment. 2. The Resident Care Coordinator will conduct weekly skill check observations on staff to ensure compliance with our infection prevention control policy and correct processes to prevent cross-contamination and infections among residents and staff. 3. Weekly 4. Executive Director & Residential Coordinator

Based on observation and interview, it was determined the facility failed to maintain effective infection prevention and control protocols to provide a safe, sanitary and comfortable environment for multiple sampled and unsampled residents. This is a repeat citation. Findings include, but are not limited to: Observations made from 08/13/24 to 08/14/24 revealed the following: a. Observations of lunch service on 08/13/24 revealed multiple universal caregivers served food to residents without donning a protective barrier over potentially contaminated clothing, and delivered meals to unsampled residents in their rooms without covering the food to prevent potential contamination. b. Staff 18 (CG) was observed walking out of a resident's room with incontinent trash and single use gloves at 2:22 pm on 08/14/24. She was observed touching multiple surfaces with the soiled gloves. She disposed of the trash, doffed soiled gloves, and walked into another resident's room and assisting the resident with transferring without performing hand hygiene. The need to maintain effective infection prevention and control protocols was discussed with Staff 17 (Owner) at 9:15 am on 08/14/24. He acknowledged the findings.

1.All staff training will be conducted on 8/21/2024 regarding infection prevention and control to ensure a safe, sanitary, and comfortable environment. 2.The RCC and RSD will conduct weekly skill check observations on staff to ensure compliance with our infection prevention control policy and correct processes to prevent cross-contamination and infections among residents and staff. 3.The RCC ,RSD and Executive Director must oversee the implementation and effectiveness of these infection prevention measures.

Based on observation, interview, and record review, it was determined the facility failed to carry out treatment orders as prescribed for 1 of 1 sampled resident (#2) who had diet orders. Findings include, but are not limited to: Resident 2 was admitted to the facility in 10/2023 with diagnoses including Parkinson's disease and was identified during the acuity interview as receiving hospice services. The resident's service plan dated 01/25/24, temporary service plans, and physician orders dated 10/25/23 and 02/27/24 were reviewed, observations were made, and interviews were conducted. The following was identified: a. The resident had a physician order for a pureed diet. The International Dysphagia Diet Standardization Initiative (IDDSI) described a pureed diet as a Level 5 diet. It must not contain lumps, and must not be sticky. At 1:00 pm on 03/25/24 and 12:23 pm on 03/26/24, staff were observed to feed the resident. The texture of the food was sticky as evidenced by large portions clinging to the spoon and had visible lumps in it. b. The resident had a physician order for "[s]tart Thick-It [a product which thickens liquids] - follow package directions until the liquid drink is nectar thick in consistency." Observations made on 03/25/24 and 03/26/24 revealed staff provided the resident with non-thickened ice water from the kitchen tap on multiple occasions. No staff were observed thickening the resident's liquids as instructed on the order. The need to ensure treatment orders were carried out as prescribed was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 03/27/24. They acknowledged the findings.

1. Staff will follow physician orders and check each resident's medicine and nutrition. 2. Every new order will be reviewed daily by RN and RCC, who will make any necessary modifications.   3. This will be completed every day and whenever a new order is received. 4. Registered Nurse, Coordinator of Resident Care, and Executive Director

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and contained reasons for use, for 3 of 4 sampled residents (#s 1, 2, and 3) whose medications were reviewed. Findings include, but are not limited to: 1. Resident 3's 03/01/24 through 03/25/24 MAR was reviewed and identified 12 medications that lacked a reason for use. In an interview on 03/26/24, Staff 6 (MT) stated she did not know why the pharmacy sent the prescriptions over without a reason for use. In an interview with Staff 1 (ED) on 03/27/24, discussed that facility RN can also add reasons for use to MAR. The need to ensure accurate MARs included reasons for use was discussed with Staff 1, Staff 2 (RN), and Staff 3 (Residential Care Director) on 03/27/24. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 08/2023 with diagnoses including Lewy body dementia. The resident's 03/01/24 to 03/25/24 MARs and physician orders dated 03/19/24 were reviewed. Eight medications lacked a reason for use. The need to ensure an accurate MAR that included minimum requirements was discussed with Staff 1 (Executive Director) on 03/27/24. She acknowledged the findings. 3. Resident 2 was admitted to the facility in 10/2023 with diagnoses including Parkinson's disease. The residents 03/01/24 to 03/25/24 MAR and physicians orders dated 12/29/23 were reviewed. Six medications lacked a reason for use. The need to ensure an accurate MAR that included minimum requirements was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 03/27/24. They acknowledged the findings.

1. Each prescription has a purpose for being used, and these purposes will all be reviewed by May 31, 2024. 2. The daily medication reviews by the RN and RCC will ensure that medication changes, if any, will be updated and diagnosis has been added 3. With every new prescription, this will be carried out every day. 4. ED, RCC, & RN

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 sampled staff (#s 6 and 14) completed 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including six hours on dementia care and the annual infection control training. Findings include, but are not limited to: Staff training records were reviewed on 03/26/24. Staff 6 (MT), hired 11/20/20, and Staff 14 (CG), hired 11/16/21, lacked documentation of completing annual infection control training and six hours of annual dementia care in-service training in the most recent calendar year. In an interview on 03/26/24, Staff 1 (ED) stated Staff 6 and Staff 14 had attended monthly staff meetings with training topics but acknowledged all the annual training had not been completed. On 03/26/24, the need to ensure all direct care staff completed 12 hours of annual required training, including six hours on dementia care and annual infection control training, was discussed with Staff 1. She acknowledged the findings.

1.All staff members must complete 12 hours of annual training, which consists of 2 hours on infection control and 6 hours on dementia care. All staff members must also record their attendance at monthly inservices. 2. Staff will receive reminder notes from the office manager to finish their training as needed. 3. The office manager will update the employees on whether they need to attend classes by reviewing personnel files twice a month. 4.Executive Director and Office Manager 4.

Based on interview and record review, it was determined the facility failed to conduct fire drills according to the Oregon Fire Code. Findings include, but are not limited to: Fire drill records dated 10/2023 to 03/2024 were reviewed with Staff 1 (Executive Director) at 1:37 pm on 03/26/24. There was no documented evidence the facility was completing the following: * Conducting unannounced fire drills every other month; and * Keeping a written record of the number of occupants evacuated, time to evacuate, and problems encountered relating to residents who resisted or failed to participate in fire drills. During the record review, Staff 1 stated the facility was conducting fire drills every three months, and they were not evacuating any residents during the drills. The need to ensure the facility conducted fire drills according to Oregon Fire Code was discussed with Staff 1 on 03/27/24. She acknowledged the findings.

1. Fire Drill is being held every other month and resident evacuation plan. 2. Fire drills will follow the process now listed on the new Fire & Life Safety forms. 3. Fire & Life safety will be visted as needed to ensure community compliance.   4. Executive Director & Maintenance Director

Based on interview and record review, it was determined the facility failed to ensure annual reinstruction of fire and life safety procedures to residents according to Oregon Fire Code. Findings include, but are not limited to: During an interview at 1:44 pm on 03/26/24, Staff 1 (Executive Director) stated the facility had not developed a system to complete annual reinstruction to residents regarding the facility's fire and life safety procedures. Therefore, there was no documentation to review. The need to ensure documentation of annual reinstruction of the facility's fire and life safety procedures to residents was discussed with Staff 1 on 03/27/24. She acknowledged the findings.

1. The resident and their family will consider fire and life safety training at the next care plan meeting. The resident care plan will include information about and documentation of the teaching and training of alternate escape routes. 2. The care plan, which will be reviewed, will be updated with the new Fire and Life Safety checklist. 3. Quarterly 4. Executive Director

Based on interview and record review, it was determined the facility failed to ensure annual re-instruction of fire and life safety procedures to residents according to Oregon Fire Code. This is a repeat citation. Findings include, but are not limited to: On 08/13/24 at 2:08 pm, Staff 16 (Office Manager) stated there was a system discussed for the annual re-instruction of fire and life safety procedures to residents, but there was no documentation that a system had been implemented. On 08/14/24 at 11:06 am, Staff 17 (Owner) and Staff 3 (Residential Care Director) confirmed the lack of documentation of annual re-instruction of fire and life safety procedures to residents. The need to ensure documentation of annual re-instruction of the facility's fire and life safety procedures to residents was discussed with Staff 17 and Staff 3 on 08/14/24. They acknowledged the findings.

1. The fire and life safety training has been added to care plan meeting. The resident care plan will include information about and documentation of the teaching and training of alternate escape routes. 2. The care plan, which will be reviewed, will be updated with the new Fire and Life Safety checklist. 3. Quarterly 4. Executive Director.

Based on observation and interview, it was determined the facility failed to ensure locked storage for chemicals, and other toxic materials. Findings include, but are not limited to: The facility was toured at 10:15 am on 3/25/24. Observations revealed bleach and other chemical cleaners in unlocked storage in the following areas: * Cottage 'A' laundry room; and * Cottage 'B' basement kitchenette under the sink. The need to ensure locked storage for chemicals and other toxic materials was discussed with Staff 1 (Executive Director) on 03/27/24. She acknowledged the findings.

1. All hazardous and chemical materials will be kept locked in the storage area. 2. The Executive Director and Maintenance Director will walk the laundry rooms and under the kitchenette sink once a week to look for any stored things. 3. Each week, this will be completed. 4. Executive Director, Maintenance Director

Based on observation and interview, it was determined the facility failed to ensure the interior was maintained in clean and good repair and free from unpleasant odors. Findings include, but are not limited to: The interiors of Cottage 'A' and Cottage 'B' were toured at 10:15 am on 03/25/24. The following was identified: 1. Facility-wide, there was a buildup of dust, dirt, splashes, stains, and black scuffs on the walls, doors, door frames, ceiling fans, vents, ledges, and baseboards. 2. In Cottage 'A,' the following was observed: * An unpleasant odor in the hall near Rooms 3 and 4 that did not dissipate; * The couch in the activities area was badly stained; * A wood arm chair in the activities area had a broken arm; * A lounge chair outside of Room 6 was badly stained; * The baseboards in the laundry room and the door frame in the shower room across from the laundry room were warped with water damage; * The carpet in the hall of the laundry room had large stains; and * The bottom ledge in the shower room across from the laundry room was peeling away from the floor. 3. In Cottage 'B,' the following was observed: * The main entrance door was rusted on the inside and the outside; * The interior door frame of the main entrance door was chipped on both sides on the bottom; * The laundry room had a strong mildew odor that did not dissipate; * The bathmat in the basement shower room was worn with black matter around the edges; * The shower rod in the basement shower room was rusted; * There was an inch-wide crack between the basement shower room floor and the hall floor; and * There was an unpleasant odor in the hall outside of Room 12 in the basement that did not dissipate during the survey. The need to ensure the facility was maintained clean and in good repair and free from unpleasant odors was discussed with Staff 1 (Executive Director) on 03/27/24. She acknowledged the findings.

1. The staff cleaning task has been revised, and the maintenance director will now follow the new carpet cleaning timetable. 2. By May 31, 2024, every location that requires attention will be cleaned, and a weekly spot check will be conducted on every area. 3. Daily & Weekly 4. Executive Director ,Maintenance Director

Based on observation and interview, it was determined the facility failed to ensure the interior was maintained in clean and good repair and free from unpleasant odors. This is a repeat citation. Findings include, but are not limited to: The facility was toured on 08/13/24 at 9:45 am. The following was identified: 1. Facility-wide, there was a buildup of dust, dirt, splashes, stains, and black scuffs on the walls, doors, door frames, vents, ledges, and baseboards. 2. In Cottage 'A,' the following was observed: * The couch in the activities area was stained and torn; * The baseboards in the laundry room and the door frame in the shower room across from the laundry room were warped with water damage; and * The carpet throughout the building was stained. 3. In Cottage 'B,' the following was observed: * The main entrance door was rusted on the inside and the outside; * The interior door frame of the main entrance door was chipped on both sides on the bottom; * The white couch in the sun room had stains on the front, seat, and arms; and * There was an unpleasant odor in the hall outside of Room 12 in the basement that did not dissipate during the survey. The building was toured with Staff 17 (Owner) and the areas needing cleaning and repair as well the area with unpleasant odors were reviewed. He acknowledged the findings.

1. The maintenance director is going to follow to the updated carpet cleaning schedule, and the staff cleaning duty has been updated to include the rail, walls, and doors. We are going to order some new furniture. We have plans to order a new door for cottage B. 2.  Every location that requires attention will be cleaned, and a weekly spot check will be conducted on every area. 3. Every week 4. Executive Director ,Maintenance Director,Housekeeper

Based on interview and record review, it was determined the facility failed to ensure soiled linens and soiled clothing were washed with a minimum rinse temperature of 140 degrees Fahrenheit or a chemical disinfectant. Findings include, but are not limited to: The facility's March temperature logs were reviewed at 2:00 pm on 03/26/24. The logs indicated the facility washing machines rinse temperatures ranged from 115 to 118 degrees Fahrenheit. During an interview at 2:14 pm on 03/26/24, Staff 16 (Office Manager) confirmed the facility was not using a detergent that contained disinfectant for soiled laundry. The need to ensure a minimum rinse temperature of 140 degrees Fahrenheit or use of a chemical disinfectant for soiled linen and clothing was discussed with Staff 1 (Executive Director) on 03/27/24. She acknowledged the findings.

1.Disinfectant detergent will be used to clean all soiled clothes and linens. 2.There will always be a disinfecting detergent on hand to clean up soiled laundry.   3. Every day. 4. Staff that provide direct care, Housekeeping, and Executive Director

Based on observation and interview, it was determined the facility failed to ensure washers for soiled laundry had a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant was used. This is a repeat citation. Findings include, but are not limited to: Observations of the Cottage B laundry room and janitorial closet were made at 11:54 am on 08/13/24. The washing machine did not have a temperature gauge to ensure a rinse temperature of 140 degrees Fahrenheit. There was no disinfectant observed in either the laundry room or the closet. During an interview at 11:55 am on 08/13/24, Staff 18 (CG) stated she used one detergent for all laundry. The detergent did not contain a disinfectant. During an interview at 12:05 pm on 08/13/24, Staff 13 also confirmed she used one detergent for all laundry that did not contain a disinfectant. The need to ensure to ensure washers for soiled laundry had a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant was used was discussed with Staff 17 (Owner) at 9:43 am on 08/14/24. He acknowledged the findings.

1.Disinfectant detergent will be used to clean all soiled clothes. 2.There will always be a disinfecting detergent on hand to clean up soiled laundry.   3. Every day. 4. Staff that provide direct care, Housekeeping, and Executive Director

Based on observation, interview, and record review, it was determined the facility failed to ensure the relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C295, C422, C513, and C530.

Refer to C 240

The findings of the re-licensure survey conducted 03/25/24 through 03/27/24 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 and OARs 411 Division 004 Home and Community Based Services Regulations. 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 re-visit to the re-licensure survey of 03/27/24, conducted 08/13/24 through 08/14/24, 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 004 for Home and Community Based Services Regulations. 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 03/27/24, conducted 10/10/24, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation and interview, it was determined the facility failed to ensure food was prepared, and the kitchen was maintained, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the facility main kitchen in Building A, service kitchen in Building B, food storage areas, food preparation, and food service on 01/30/23 revealed: *Building A: - The garbage in the food prep area had no lid; - Interior and behind the ovens had a buildup of grease and debris; - Interior of the freezer and refrigerator has spills and splatters; - A dish rack was stored on the floor; - The prep area back-splash had spills and splatters; and - Multiple bins had scoops with handles in the food. *Building B: - Multiple drawer interiors had spills, splatters, and debris; - Multiple cupboards were damaged, creating and uncleanable surface and had spills, splatters, and debris; and - The dishwasher was removed and staff were hand washing dishes without sanitizing them. The facility began transporting dishes to Building A for sanitation. The kitchens were toured with Staff 2 (Head Chef). She acknowledged the areas in need of cleaning. The areas in need of cleaning and repair were reviewed with Staff 1 (Executive Director). She acknowledged the findings.

Building A: - New garbege bine with a lid has been replaced. -There is a cleaning plan in place with daily chores for the employees to complete. The ED will perform a weekly check to ensure tasks are completed. -Dish racks are situated on a shelf. -Beside the food storage space, a scoop holder has been placed. Bulding B: -There is a cleaning plan in place with daily chores for the employees to complete. The ED will perform a weekly check to ensure tasks are completed. -The damaged cabinets have been repaired. -Dishwasher was repaired.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: Observations of the facility's main kitchen in Building A, service kitchen in Building B and food storage areas on 05/18/23 revealed: Building A:   * Interior of the ovens had a buildup of grease and debris; * A dish rack was stored on the floor; * The prep area backsplash had spills and splatters; and * Walls, flooring, pipes and electrical outlets around the sink had spills and splatters. Building B: * Multiple drawer interiors and exteriors had spills, splatters and debris; * Multiple drawers and cupboards were damaged with particle board exposed creating uncleanable surfaces; * Cupboard door below sink was broken; and * Multiple cupboards had spills, splatters, garbage and debris. The areas in need of cleaning and repair were observed and reviewed with Staff 1 (Executive Director) on 05/18/23. She acknowledged the findings.

Building A: - Interior of the ovens has been cleaned and ad to daily cleaning schedule . ED will perform a weekly check to ensure tasks are completed. -Extra Dish rack was removed . -the perp area backsplash was cleaned and ad to daily cleaning schedule.ED will perform a weekly check to ensure tasks are completed. -Wall, flooring, pipes and electical outlet, aroung sink area was cleaned and ad to dailt cleaning schedule, ED will perform a weekly check to ensure tasks are completed. Bulding B: -There is a cleaning plan in place with daily chores for the employees to complete. The ED will perform a weekly check to ensure tasks are completed. -The broken cabinets were taken out, and we covered the unusable cabinets with plastic sheets until our remodeling was finished in three to six months. -All dishes will be washed in the cottage A. While we are waitting  for our remodeling to be finished in three to six months.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: Observations of the facility's main kitchen in Building A, service kitchen in Building B and food storage areas on 07/06/23 revealed: Building A:   * The bottom left corner of the dishwashing sink was leaking water. Building B: * Some cupboards with exposed particle board had been repaired. However, the majority still had exposed particle board rendering the surfaces uncleanable and the material used to cover the broken cupboards was a rough, uncleanable plywood; * The cupboard door below sink was broken; * Multiple cupboard interiors had spills, splatters, garbage and debris; * The gap between floor and stove had black matter buildup, dust, and food debris; * The space between the sink and the countertop had black matter buildup; and * The counter and backsplash behind the sink had a half-inch gap. The areas in need of cleaning and repair were observed and reviewed with Staff 1 (Executive Director) on 07/07/23. She acknowledged the findings.

Cottage A - The left-bottom corner of the sink used for washing dishes is repaired. Cottage B: -The damaged cabinets were removed, and we painted and covered them with plywood until our renovation project was complete, which took three to six months. -There is a cleaning schedule for staff to follow. To make sure chores are finished, the ED will conduct a weekly check. -The space between the floor and the stove was cleaned, and the cover was replaced. -New caulking was applied between the countertop and backsplash as well as the sink and countertop.

Based on observation and interview, it was determined the facility failed to ensure the kitchen inspection survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 240.

Refer to C 240

Based on observation and interview, it was determined the facility failed to ensure the kitchen inspection survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to: Refer to C 240.

Refer to C 240

The findings of the kitchen inspection, conducted 01/30/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the first revisit to the kitchen inspection of 01/30/23, conducted 05/18/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the second revisit to the kitchen inspection of 01/30/23, conducted 07/06/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the third revisit to the kitchen inspection of 01/30/23, conducted 09/15/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.