Clearwater Beaverton

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 kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 05/19/26 at 10:45 am, the facility kitchen was observed to need cleaning in the following areas: * Stainless steel wall behind cooking equipment – drips of grease; * Exterior area of hood over cooking equipment – greasy, handprints; * Side of steamer – food splatters; * Sides of grill and deep fat fryer – drips of grease * Front of deep fryer and refrigerator on cooking line – smears/drips; and * Wall underneath spray hose sink in dishwashing area – significant build up of black matter. Other areas of concern included: * Cutting board on service line – scored and stained and * Slicer not covered when not in use. Improper food storage included: *Dry storage – open bags of dry pasta without being dated, container of dried raisins not securely covered to prevent potential contamination and *Walk in refrigerator had open and/or uncovered food items without dates – bag of hashbrowns, cooked piece of meat, crab and meat patties, churros, lava cakes and French fries. The areas of concern were discussed with Staff 1 (Culinary Director), Staff 2 (Lead Cook) and Staff 3 (Executive Director) on 05/19/26 and the findings were acknowledged at 12:45 pm.

Deficiency #1: Stainless Steel Wall Behind Cooking Equipment with Drips of Grease 1. What actions will be taken to correct the rule violation for each example? The stainless steel wall behind the cooking equipment was thoroughly cleaned and degreased immediately upon identification of the deficiency. Kitchen staff were instructed on proper cleaning procedures and expectations for maintaining cleanliness in food preparation areas. 2. How will the system be corrected so this violation will not happen again? The kitchen cleaning schedule has been updated to ensure quarterly deep cleaning is consistently completed by an outside vendor, including routine cleaning of the stainless steel walls behind cooking equipment. If the vendor is unavailable on the scheduled date, services will be rescheduled as soon as possible to maintain compliance. In addition, staff will receive ongoing education regarding sanitation standards, proper kitchen cleaning practices, and accountability for maintaining a clean and sanitary environment. Staff will complete and sign off on daily and weekly cleaning checklists at closing. 3. How often will the area needing correction be evaluated? The area will be inspected daily by the culinary leadership team and included in daily and weekly audits to ensure continued compliance. 4. Who will be responsible to see that the corrections are completed/monitored? The Culinary Director, Sous Chef, Restaurant Supervisor, Administrator and/or designee will be responsible for ensuring the corrections are completed and monitored on an ongoing basis. Deficiency #2: Exterior Area of Hood Over Cooking Equipment with Grease and Handprints 1. What actions will be taken to correct the rule violation for each example? The exterior area of the hood over the cooking equipment was thoroughly cleaned and degreased immediately upon identification of the deficiency. Staff were reminded of sanitation expectations and proper cleaning procedures for kitchen equipment and surrounding surfaces. 2. How will the system be corrected so this violation will not happen again? The kitchen cleaning schedule has been updated to ensure quarterly deep cleaning by an outside vendor, including routine cleaning and inspection of exterior hood surfaces during daily closing duties. If the vendor is unavailable on the scheduled date, services will be rescheduled as soon as possible to maintain compliance. Staff will receive ongoing education regarding sanitation standards, proper cleaning techniques, and accountability for maintaining a clean kitchen environment. Daily and weekly cleaning checklists will be completed and signed off at closing. 3. How often will the area needing correction be evaluated? The area will be inspected daily by the culinary leadership team and included in daily and weekly sanitation audits to ensure continued compliance. 4. Who will be responsible to see that the corrections are completed/monitored? The Culinary Director, Sous Chef, Restaurant Supervisor, Administrator, and/or designee will be responsible for ensuring the corrections are completed and monitored on an ongoing basis. Deficiency #3: Side of Steamer – Food Splatters 1. What actions will be taken to correct the rule violation for each example? The side of the steamer with visible food splatters was immediately cleaned, scrubbed, and sanitized upon identification of the deficiency. Staff were reminded of proper cleaning procedures and the importance of maintaining all kitchen equipment in a sanitary condition, including hard-to-reach and high-use surfaces. 2. How will the system be corrected so this violation will not happen again? The kitchen cleaning schedule has been updated to ensure that steamers and all cooking equipment are included in daily closing cleaning procedures. Staff will receive ongoing education on sanitation standards and proper cleaning techniques for equipment surfaces. Daily and weekly cleaning checklists will be completed and signed off to ensure accountability. 3. How often will the area needing correction be evaluated? The area will be inspected daily by the culinary leadership team and included in daily and weekly sanitation audits to ensure continued compliance. 4. Who will be responsible to see that the corrections are completed/monitored? The Culinary Director, Sous Chef, Restaurant Supervisor, Administrator and/or designee will be responsible for ensuring all corrections are completed and consistently monitored. Deficiency #4: Sides of Grill and Deep Fat Fryer – Drips of Grease 1. What actions will be taken to correct the rule violation for each example? The sides of the grill and deep fat fryer were immediately cleaned, degreased, and sanitized upon identification of the deficiency. Staff were instructed on proper cleaning procedures and the importance of maintaining all cooking equipment surfaces in a sanitary condition during and after each use. 2. How will the system be corrected so this violation will not happen again? The kitchen cleaning schedule has been updated to ensure that grills and deep fat fryers are included in daily closing cleaning procedures. Staff will receive ongoing education on sanitation standards and proper cleaning techniques for high-use equipment. Daily and weekly cleaning checklists will be completed and signed off at closing to ensure accountability and consistency. 3. How often will the area needing correction be evaluated? The area will be inspected daily by the culinary leadership team and included in daily and weekly sanitation audits to ensure continued compliance. 4. Who will be responsible to see that the corrections are completed/monitored? The Culinary Director, Sous Chef, Restaurant Supervisor, Administrator and/or designee will be responsible for ensuring all corrections are completed and consistently monitored. Deficiency #5: Front of Deep Fryer and Refrigerator on Cooking Line – Smears/Drips 1. What actions will be taken to correct the rule violation for each example? The front of the deep fryer and refrigerator on the cooking line were immediately cleaned, degreased, and sanitized upon identification of smears and drips. Staff were reminded of proper sanitation procedures and the importance of maintaining cleanliness on all high-touch and high-visibility kitchen surfaces. 2. How will the system be corrected so this violation will not happen again? The kitchen cleaning schedule has been updated to ensure that the front surfaces of the deep fryer and refrigerator are included in daily closing cleaning procedures. Staff will receive ongoing education on sanitation standards and proper cleaning techniques. Daily and weekly cleaning checklists will be completed and signed off at closing to ensure accountability and consistency. 3. How often will the area needing correction be evaluated? The area will be inspected daily by the culinary leadership team and included in daily and weekly sanitation audits to ensure continued compliance. 4. Who will be responsible to see that the corrections are completed/monitored? The Culinary Director, Sous Chef, Restaurant Supervisor, Administrator and/or designee will be responsible for ensuring all corrections are completed and consistently monitored. Deficiency #6: Cutting Board on Service Line – Scored and Stained 1. What actions will be taken to correct the rule violation for each example? The cutting board on the service line that was found to be scored and stained was immediately removed from service. It was replaced with a clean, sanitary cutting board that meets health and safety standards. Staff were instructed on proper inspection of food contact surfaces and the importance of replacing damaged or heavily worn equipment promptly. 2. How will the system be corrected so this violation will not happen again? A routine inspection process has been implemented to ensure all cutting boards are checked regularly for scoring, staining, and wear. Damaged boards will be replaced immediately as needed. Staff will receive ongoing training on sanitation standards and proper maintenance of food contact surfaces to prevent cross-contamination risks. 3. How often will the area needing correction be evaluated? Food contact surfaces, including cutting boards, will be inspected daily by culinary leadership and included in daily and weekly sanitation audits to ensure compliance. 4. Who will be responsible to see that the corrections are completed/monitored? The Culinary Director, Sous Chef, Restaurant Supervisor, Administrator and/or designee will be responsible for ensuring all corrections are completed and consistently monitored. Deficiency #7: Slicer Not Covered When Not in Use 1. What actions will be taken to correct the rule violation for each example? The slicer was immediately cleaned, sanitized, and properly covered upon identification of the deficiency. Staff were reminded that all food preparation equipment must be cleaned, sanitized, and covered when not in use to maintain safe food handling practices. 2. How will the system be corrected so this violation will not happen again? The kitchen procedures have been reinforced to ensure the slicer is included in the daily cleaning, sanitizing, and end-of-shift equipment shutdown checklist. Staff will receive ongoing education on safe food handling practices, including proper equipment covering and storage when not in use. Compliance will be reinforced through daily shift checklists and supervisory oversight. 3. How often will the area needing correction be evaluated? The slicer and surrounding food prep area will be inspected daily by culinary leadership and included in daily and weekly sanitation audits to ensure ongoing compliance. 4. Who will be responsible to see that the corrections are completed/monitored? The Culinary Director, Sous Chef, Restaurant Supervisor, Administrator and/or designee will be responsible for ensuring all corrective actions are completed and consistently monitored. Deficiency #8: Dry Storage – Open Bags of Dry Pasta Not Dated; Container of Dried Raisins Not Securely Covered 1. What actions will be taken to correct the rule violation for each example? The open bags of dry pasta were immediately sealed, labeled, and dated upon identification of the deficiency. The container of dried raisins was discarded due to being improperly stored. Staff were reminded of proper dry storage procedures, including labeling, dating, and ensuring all food items are stored in covered, sanitary containers. 2. How will the system be corrected so this violation will not happen again? The dry storage area procedures have been reinforced to ensure all food items are properly labeled, dated, and stored in sealed, food-safe containers immediately upon opening. Staff will receive ongoing education on dry storage standards, including first-in-first-out (FIFO) practices and contamination prevention. Daily and weekly storage audits will be conducted to ensure compliance. 3. How often will the area needing correction be evaluated? Dry storage areas will be inspected daily by culinary leadership and included in daily and weekly sanitation audits to ensure ongoing compliance. 4. Who will be responsible to see that the corrections are completed/monitored? The Culinary Director, Sous Chef, Restaurant Supervisor, Administrator and/or designee will be responsible for ensuring all corrections are completed and consistently monitored. Deficiency #9: Walk-In Refrigerator – Open and/or Uncovered Food Items Without Dates 1. What actions will be taken to correct the rule violation for each example? All open and/or uncovered food items in the walk-in refrigerator were immediately covered, labeled, and dated upon identification of the deficiency. This included bags of hashbrowns, cooked meat items, crab and meat patties, churros, lava cakes, and French fries. Any items that could not be verified for safe storage or proper dating were discarded. Staff were reminded of proper food storage procedures, including labeling, dating, and ensuring all food items are properly covered to prevent contamination. 2. How will the system be corrected so this violation will not happen again? The walk-in refrigerator procedures have been reinforced to ensure all food items are properly labeled, dated, and stored in covered, food-safe containers immediately after preparation or opening. Staff will receive ongoing education on food safety standards, including proper cooling, storage, and first-in-first-out (FIFO) practices. Daily and weekly refrigerator audits will be conducted to ensure compliance. 3. How often will the area needing correction be evaluated? The walk-in refrigerator will be inspected daily by culinary leadership and included in daily and weekly sanitation audits to ensure ongoing compliance. 4. Who will be responsible to see that the corrections are completed/monitored? The Culinary Director, Sous Chef, Restaurant Supervisor, Administrator and/or designee will be responsible for ensuring all corrections are completed and consistently monitored.

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

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240.

Please referencing to tag C0240

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

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 4) whose move-in evaluation was reviewed. Findings include, but are not limited to: Resident 4 moved into the assisted living community in 01/2026 with diagnoses including congestive heart failure. On 01/13/26 at 9:57 am, the resident’s move-in evaluations, dated 12/24/25 and 01/02/26, were reviewed with Staff 1 (Executive Director) and Staff 2 (Health Services Director), and the following required elements were not addressed: * Mental health issues, including presence of depression, thought disorders or mood problems, and effective non-drug interventions; * Pain, including non-pharmaceutical interventions; * Emergency evacuation ability; * Decision making ability; * Recent losses; * Unsuccessful prior placements; * Ability to smoke safely; * Drug use; * Environmental factors that impact the resident’s behavior including but not limited to noise and room temperature; and * Gender identity. The need to ensure move-in evaluations addressed each required element was reviewed with Staff 1, Staff 2, Staff 3 (Memory Support Director), and Staff 6 (Health Services Assistant) on 01/14/26 at 2:37 pm. They acknowledged the findings.

1. What actions will be taken to correct the rule violation for each example/resident? The facility acknowledges the cited deficiency related to incomplete Resident Move-In Evaluations that did not address all required elements. Immediate corrective actions have been taken as outlined below: Resident #4: The move-in evaluation for Resident #4 has been corrected to address all required elements, including: a) Mental Health Issues b) Pain, Including Non-Pharmaceutical Interventions c) Emergency Evacuation Ability d) Decision-Making Ability e) Recent Losses f) Unsuccessful Prior Placements g) Ability to Smoke Safely h) Drug Use i) Environmental Factors Impacting Behavior j) Gender Identity 2. How will the system be corrected so this violation will not happen again? a) The Health Services Director, Memory Support Director, Health Services Assistant, and Administrator will receive training on completing Resident Move-In Evaluations and the importance of addressing all required elements in accordance with OAR 411-054-0034(5). 3. How often will the area needing correction be evaluated? a) All Resident Move-In Evaluations will be reviewed prior to the resident’s move-in date to ensure all required elements are completed. b) The Health Services Director, Health Services Assistant, Administrator, and/or designee will conduct random audits to ensure continued compliance with OAR 411-054-0034(5). 4. Who will be responsible to see that the corrections are completed and monitored? a) The Health Services Director, Memory Support Director, Health Services Assistant, Administrator, and/or designee are responsible for ensuring corrections are completed and monitored. 5. Date facility alleges compliance a) The facility alleges compliance as of March 15, 2026.

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 411-054-0034 (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 pronouns and gender identity were evaluated prior to or upon move-in. Findings include, but are not limited to: Refer to C252.

Please refer to C0252 above. Facility alleges compliance by March 15, 2026.

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.