Mt. Angel Orchard House

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 observation, interview, and record review, it was determined the facility failed to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff, and document progress until the condition resolved for 2 of 3 sampled residents (#s 1 and 2) who experienced short-term changes of condition. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 09/2025 with diagnoses including chronic diastolic heart failure, dysphagia (difficulty swallowing), and severe protein-calorie malnutrition. Resident 1’s clinical records from 10/16/25 through 01/12/26 were reviewed, and the following was identified: * On 10/22/25, the resident resumed taking Eliquis (blood thinner) 2.5 mg twice daily. There was no documented evidence staff had been provided monitoring instructions for the change in medication or the medication change had been monitored through resolution; * Staff documented the resident’s dosage for Klor-Con (for low potassium levels) was increased, and on 11/06/25 the medication frequency was increased to twice daily. There was no documented evidence staff had been provided monitoring instructions for the change in medication or the medication change had been monitored through resolution; * On 11/08/25, Resident 1 returned to the facility after a visit to the emergency department related to having black stool. There was no documented evidence staff had been provided monitoring instructions for the resident upon return from the hospital or that the resident had been monitored through resolution; * On 11/14/25, staff documented Resident 1 “continues to have intermittent diarrhea of dark stools.” There was no documented evidence staff had been provided monitoring instructions or that the resident’s diarrhea had been monitored through resolution; * On 11/24/25, the resident started Imodium to treat intermittent diarrhea. There was no documented evidence staff had been provided monitoring instructions for the change in medication or the medication change had been monitored through resolution; and * Resident 1 was hospitalized from 12/18/25 through 12/27/25 related to abdominal pain and was diagnosed with severe dilation of gallbladder. Upon discharge from the hospital, Resident 1 was admitted to hospice. There was no documented evidence staff had been provided monitoring instructions or the resident had been monitored through resolution for any complications following hospitalization. During an interview on 01/14/26 at 12:45 pm, Staff 2 (RN Case Manager) confirmed the lack of documented evidence staff were provided monitoring instructions and the resident had been monitored through resolution for the short-term changes of condition. The need to ensure the facility had a system in place to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff, and document progress until the condition resolved evaluate and monitor each resident consistent with his or her evaluated needs and service plan was reviewed with Staff 1 (Administrator) and Staff 2 on 01/15/26 at 12:57 pm. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 03/2017 with diagnoses including multiple sclerosis and paraplegia. The resident’s clinical record from 10/16/25 through 01/12/26 was reviewed, interviews with staff were conducted, and observations were made. The following was identified: The resident’s service plan, dated 11/14/25, identified a chronic right buttock wound, which the facility had been managing since admission in 2017. Resident 2 had orders for twice weekly wound care by MTs, who were instructed and supervised by the facility RN. The service plan indicated the RN would perform weekly skin checks on the wound. Review of progress notes dated 10/16/25 through 01/12/26 identified the following; * On 01/03/26 during routine wound cares, staff documented, “I did notice on the other side of [Resident 2’s] bottom is a small area that looks like it could open up.” There was no documented evidence the facility determined and documented resident-specific actions or intervention needed for the new skin issue, communicated the action or intervention to staff on all shifts, or monitored progress through resolution. The RN had not completed a skin check for Resident 2’s chronic wound after 12/15/25. On 01/14/26 at 12:35pm, Staff 2 (RN Case Manager) confirmed there were no interventions determined for the new skin issue identified on 01/03/26 and no monitoring at least weekly through resolution for Resident 2’s skin condition from 12/15/25 through 01/12/26. On 01/14/26 at 12:35 pm, the RN confirmed she had not documented weekly skin notes on the resident’s wound between 12/15/25 and 01/12/25. The need to ensure the facility determined resident-specific actions or interventions were needed for short-term changes of condition and monitored the condition at least weekly through resolution was discussed with Staff 1 (Administrator) and Staff 2 on 01/15/26 at 11:40 am. They acknowledged the findings.

1. Correction: • For Resident #1 RN completed a review of all change-of-condition events prior to 12/27/25 and identified where documentation or instructions were incomplete. • Upon hospice admission on 12/27/25, RN documented the transition in PCC and updated the service plan to reflect hospice as the clinical lead. • Comfort-focused monitoring was implemented and communicated to all staff. • Staff re-trained on reporting Change of Condition. 2. Prevention: The facility has fully implemented a standardized Change of Condition Monitoring System, which includes the following components: A. Alert Charting (eMAR) • RN initiates Alert Charting for all Change of Conditions. • Caregivers complete Alert Charting each shift until the RN discontinues it based on clinical resolution B. RN Communication (eMAR) RN documents: • Resident placed on Alert Charting • Temporary Service Plan started • Reason for the change of condition • This ensures written communication to all shifts. C. Temporary Service Plan • RN creates a resident-specific Temporary Service Plan including: o Monitoring parameters o Signs/symptoms to report o Criteria for notification to RN or calling 911 The Temporary Service Plan is placed in the medication cart folder and updated/initialed by the RN as changes occur. D. Weekly RN Review • RN reviews the Temporary Service Plan, Alert Charting, and staff notes at least weekly, documenting assessment and changes. E. eMAR Task for Caregivers • Caregivers must document: “Reviewed Temporary Service Plan this shift.” • This creates shift-to-shift evidence of compliance F. Staff Reporting Expectations • Staff report all changes through eMAR Communication. • RN follows up with timely assessment, interventions, and documentation. • This ensures a consistent 24-hour reporting system for all changes of condition G. RN Progress Notes • RN documents weekly progress and interventions until resolution or determination of a new baseline. H. Temporary Service Plan Closure • RN closes the Temporary Service Plan when resolved. • Service plan updates are completed as needed. These processes ensure all changes of condition are identified promptly, communicated across shifts, and clinically followed through to resolution 3. Monitoring and Frequency: • RN will complete weekly chart audits (minimum 10%) of active changes of condition. • RCC will verify shift-to-shift communication and Temporary Service Plan compliance weekly. • Administrator will review Change of Condition compliance monthly and evaluate trends quarterly in Quality Assurance Performance Improvement. 4. Who Is Responsible: • RN Case Manager – Primary oversight • RCC – Secondary reviewer • Administrator – Quality Assurance monitoring & enforcement For Resident #2 1. Correction: • Implemented Skin Sheet to identify new area of concern. • RN completed wound assessment and added wound care instructions to Service Plan. • RN re-established weekly Task, Wound & Skin Log tracker. • Service plan and eMAR updated with wound care instructions. • Staff re-trained on reporting new skin concerns and notification protocol. 2. Prevention: (All Change of Condition system elements listed in Finding #1 also apply here. This ensures a consistent, facility-wide system for identifying, monitoring, and resolving clinical changes.) In addition, the following wound-specific measures were added: • Mandatory weekly RN skin checks with documentation in the Task, Wound & Skin Log and in a weekly RN progress note. • Temporary Service Plan required for all skin changes, including monitoring parameters and RN/911 call criteria. • Caregivers must immediately report any new skin issues on Skin Sheet. • Weekly RN/RCC wound audits implemented to ensure compliance. 3. Monitoring and Frequency: • RN will review all wound documentation weekly, including the Task, Wound & Skin Log, Temporary Service Plans, and progress note • RCC will verify communication and Temporary Service Plan use weekly. • Administrator will review five wound-related Change of Condition events monthly and evaluate trends quarterly in Quality Assurance Performance Improvement. 4. Who is responsible: • RN – Primary oversight • RCC – Secondary review • Administrator – Quality Assurance oversight

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory care communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up.

Based on observation and interview, it was determined the facility failed to ensure pathways were made of smooth material and maintained in good repair, and measures were taken to prevent the entry of flies, mosquitoes, and other insects. Findings include, but are not limited to: The exterior of the facility was toured on 01/12/26 at 11:00 am and revealed the following: * Concrete pathways near the front entrance were observed with gouges and chipped seams; * A raised seam in the concrete pathway leading to/from the south access door posed a tripping hazard; and * Seventeen windows on the second floor of the facility and eight windows on the first floor were missing screens, and multiple screens were not fastened securely to their frames. In an interview on 01/13/26 at 1:40 pm, Staff 3 (Maintenance Supervisor) stated the window screens had been removed last summer by a cleaning company and were not replaced. The facility’s exterior was toured with Staff 1 (Administrator) and Staff 3 on 01/15/26 at 10:20 am. They acknowledged the findings.

1. Front Entrance Concrete 1. Action: • Maintenance filled minor gouges and chipped seams immediately to remove tripping hazards and restore a smooth surface. • Maintenance engaged a contractor to fully restore the pathway surface to required condition. • All identified areas were made safe and cleanable immediately while permanent repairs proceed. 2. Prevention: • Concrete surfaces added to monthly exterior rounds. • Freeze/thaw inspection added seasonally to detect damage. • Staff re-education to report any exterior surface deterioration immediately. 3. Monitor and Who • Maintenance Director monitors repairs weekly until completed; then monthly via Environmental Rounds check list. • Administrator reviews through monthly rounds and tracks in Quality Assurance Performance Improvement for 3 months after which will review quarterly. 4. Frequency: Weekly until full repair; then monthly and quarterly. 2. South Emergency Access Door 1. Action: • Temporary cones placed to mark the raised seam and prevent resident injury. • Specialized repair to level the seam was been initiated through qualified external services on 2/4/26 2. Prevention: • All pathway seams added to the Environmental Rounds checklist. • Staff educated on identifying and reporting trip hazards immediately. 3. Monitor: • Maintenance Director will inspect the area weekly until fully repaired, then monthly through Environmental Rounds. • Administrator will review findings monthly and monitor through Quality Assurance Performance Improvement for three months and then quarterly. 4. Frequency: Weekly until full repair; then monthly. 3. Missing or Loose Window Screens 1. Action: • Full inventory of all screens completed. • Loose screens secured immediately. • Replacement screens ordered and installation was initiated on 2/4/26 to ensure all windows have properly fitted, secure screens. 2. Prevention: • Window screen inspection added to monthly Environmental Rounds. • Quarterly window and frame inspection added to ongoing maintenance program. 3. Monitor and Who: • Maintenance Director will verify installation and screen integrity weekly until complete, then monthly through Environmental Rounds. • Administrator will review findings in Quality Assurance Performance Improvement for three months after which will review quarterly. 4. Frequency: Weekly until full repair; then monthly. Then quarterly.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair.

Based on observation and interview, it was determined the facility failed to ensure all interior surfaces were kept clean and in good repair. Findings include, but are not limited to: The facility’s interior was toured on 01/12/26 at 11:00 am, and the following was identified: 1. Iris Grove: * Multiple resident doors were heavily scratched and gouged, some to bare wood, and the paint on the metal door jambs was scratched; * Wood handrails throughout the Grove were scratched and gouged to bare wood in some areas; * Multiple ceiling tiles from the elevator to the fire extinguisher room were stained; and * Carpets were stained in the breezeway leading from the ALF to the SNF, outside the Custodial office and in the central sitting area. 2. Iris Grove kitchenette/ dining room: * On the wall behind the coffee maker, two areas measuring approximately 10”x10” and 10”x16” were covered with black plastic and adhered to the wall with blue painter’s tape. There were also two unpatched ¼” diameter holes in the wall, which was a different color from the rest of the room; * Multiple small holes in the wall behind the microwave oven were patched with spackle but not painted to match the color of the rest of the room; * The base cabinet beneath the coffee maker was covered with a piece of plywood that was painted black; * Baseboards were missing near the double doors that led to an outdoor patio; and * Doors to the dining room were scratched, gouged, and dented. 3. Willow Grove: * Resident doors were heavily scratched and gouged, some to bare wood, and the paint on the metal door jambs was scratched; * Wood handrails throughout the Grove were scratched and gouged to bare wood, in many areas; * Multiple ceiling tiles near rooms 122 and 123 were discolored and ill-fitting; and * Carpet was stained outside rooms 122 and 123. 4. Willow Grove kitchenette/ dining room: * The wall behind the coffee maker was patched with a 14”x14” piece of black plastic that was adhered to the wall with blue painter’s tape and was not painted to match the color of the rest of the dining room; * The wall behind the microwave oven was spackled and was not painted to match the rest of the room; * A piece of wood with two-inch diameter holes on the bottom edge and each side edge was fastened over the base cabinet under the coffee maker; and * Doors to the dining room were heavily scratched and gouged. 5. Plum Grove: * Resident doors were scratched and gouged, some to bare wood, and the paint on the metal door jambs was scratched; * Wood handrails throughout the Grove were scratched and gouged to bare wood, in many areas; * Carpets were stained outside the elevators and in front of rooms 218 and 220; * The flooring was uneven, grooved, and dipped, from room 218 to the fire doors; and * An accumulation of dead bugs and spider webs was noted along the windowsills across the loft area that overlooked the lobby. 6. Plum Grove kitchenette/ dining room: * The wall behind the coffee maker was patched with a 14”x25” piece of black plastic that was adhered to the wall with blue painter’s tape and was not painted to match the color of the rest of the dining room; * The wall behind the microwave oven was spackled and was not painted to match the rest of the room; * A piece of wood with a two-inch diameter hole on each edge was fastened over the base cabinet under the coffee maker; * Baseboards were missing in the alcove; * The window screen was on the floor, leaning against the wall; * An accumulation of dust/ lint was noted in two ceiling vents; * There were four holes in the ceiling of approximately ½” diameter; * The floor around the peninsula of the kitchenette was uneven; and * Doors to the dining room were heavily scratched and gouged to bare wood, in places. 7. Fillmore Grove: * Resident doors were scratched and gouged, some to bare wood, and the paint on the metal door jambs was scratched; * Wood handrails throughout the Grove were scratched and gouged to bare wood, in many areas; and * Carpets were stained intermittently from room 231 to the dining room. 8. Fillmore kitchenette/ dining room: * The wall behind the coffee maker was patched with a 16”x28” piece of black plastic that was adhered to the wall with blue painter’s tape and was not painted to match the color of the rest of the dining room; * The wall behind the microwave oven was spackled and was not painted to match the rest of the room; * A piece of wood with a two-inch diameter hole on each edge was fastened over the base cabinet under the coffee maker; * The wood window ledge above the sink was stained with black matter and worn to bare wood; * A sticky substance with dead ants embedded in it was noted on the backsplash above the sink; * Caulk between the stainless steel and marble counters had black matter in it; * An accumulation of dust/ lint was noted in the ceiling vents; * Three holes in the ceiling were noted of approximately ½” diameter; and * Doors to the dining room were heavily scratched and gouged to bare wood, in places. In an interview on 01/13/26 at 1:40 pm, Staff 3 (Maintenance Supervisor) stated the kitchenettes were in the middle of a full remodel and would extend to leveling the floors in the Plum Grove hallways; the renovations were budgeted for 2026, but no timeline had been determined. Potential solutions for handrail and door protectors were being investigated by the new owners, but bids had not yet been compiled. The facility’s interior was toured with Staff 1 (Administrator) and Staff 3 on 01/15/26 at 10:20 am. They acknowledged the findings.

1. IRIS- Surfaces 1. Action: • Maintenance completed immediate mitigation by repairing, sanding, and sealing scratched or gouged doors, door jambs, and handrails to restore cleanable, intact surfaces and remove exposed wood. • Full refinishing and restoration requiring specialized work beyond routine maintenance was been initiated on 2/4/26 through qualified services to ensure all surfaces are durable, uniform, and maintained in good repair. • Ceiling Tiles-All stained ceiling tiles between the elevator and the fire extinguisher room were replaced. • Carpets-Floor specialist scheduled to shampoo carpets in the breezeway, custodial hall, and central sitting area. • Maintenance will identify any areas that do not respond to professional cleaning and has submitted a flooring replacement request accordingly. areas. • All identified areas were made safe and cleanable immediately while permanent repairs or renovation proceed 2. Prevention: • Interior surfaces (doors, handrails, ceilings, carpets, walls) have been added to the monthly Environmental Rounds checklist to ensure routine monitoring and early identification of wear or damage. • Quarterly wall and door touch-up days have been implemented and will be documented and reviewed during Environmental Rounds. 3. Monitor and Who: • The Maintenance Director will monitor progress weekly until all repairs are completed, then monthly via documented Environmental Rounds. • The Administrator will provide oversight and will review items through Quality Assurance Performance Improvement for three months to ensure sustained compliance. 4. Frequency: Weekly until full repair; then monthly. 2. IRIS KITCHEN & DINING A. Action: • Maintenance removed the black plastic that had been taped to the wall behind the coffee maker; drywall was properly patched and the entire section was repainted to match. • Maintenance patched and repainted the small holes behind the microwave. • Maintenance removed the plywood that had been used as a makeshift cabinet panel and initiated installation of a proper, cleanable cabinet panel. • Missing baseboards near the patio doors were replaced to restore required cleanable surfaces. • Maintenance repaired, sanded, and repainted scratched and gouged dining room doors. B. Prevention • Kitchenette wall, cabinet, and baseboard conditions have been added to the monthly Environmental Rounds checklist to ensure ongoing monitoring. • Maintenance will complete monthly kitchenette condition checks (in addition to normal rounds) until all long-term correction work is complete. • Staff were instructed to report any damage to walls, cabinets, or surfaces immediately through the established maintenance work-order system. 3. Monitor and Who: • The Maintenance Director will monitor progress weekly until all repairs are completed, then monthly via documented Environmental Rounds. • The Administrator will review findings and sustained compliance through Quality Assurance Performance Improvement for at least three months. 4. Frequency: Weekly until full repair; then monthly 3. WILLOW – Surfaces A. Action: • Maintenance completed immediate mitigation by repairing, sanding, and sealing scratched or gouged doors, door jambs, and handrails to restore cleanable, intact surfaces and remove exposed wood. • Full refinishing and restoration requiring specialized work beyond routine maintenance was been initiated on 2/4/26 through qualified services to ensure all surfaces are durable, uniform, and maintained in good repair. • Ceiling Tiles- Discolored or ill-fitting ceiling tiles outside rooms 122–123 were replaced. • Carpet Cleaning- Floor specialist scheduled to shampoo carpets outside rooms 122–123. • Any remaining areas that do not respond to professional cleaning have been flagged for flooring replacement. B. Prevention • Interior surfaces including doors, handrails, walls, tiles, vents, and baseboards have been added to the monthly Environmental Rounds checklist. • Quarterly wall and door touch-up days have been implemented and will be documented and reviewed during Environmental Rounds. 3. Monitor and Who: • The Maintenance Director will monitor progress weekly until all repairs are completed, then monthly via documented Environmental Rounds. • The Administrator will review findings and sustained compliance through Quality Assurance Performance Improvement for at least three months. 4. Frequency: Weekly until full repair; then monthly 3. WILLOW KITCHEN & DINING A. Action • Maintenance repaired, refinished, and repainted the dining room doors to address scratches and gouges; removed the black plastic, patched and repainted the wall to match the room, repaired small holes to restore a cleanable surface, removed the plywood panel and initiated installation of a proper cabinet front, and replaced missing baseboards to ensure all surfaces are cleanable and in good repair. B. Prevention • All kitchenette surfaces including walls, cabinets, and baseboards have been added to the monthly Environmental Rounds checklist for ongoing inspection. • A quarterly interior condition audit has been added to the maintenance schedule to identify and correct early signs of damage. • Staff were instructed to report any damaged surfaces through same-day work orders to ensure prompt correction. 3. Monitor and Who: • The Maintenance Director will monitor progress weekly until all repairs are completed, then monthly via documented Environmental Rounds. • The Administrator will review findings and sustained compliance through Quality Assurance Performance Improvement for at least three months. 4. Frequency: Weekly until full repair; then monthly 5. PLUM Surfaces A. Action • Maintenance completed immediate mitigation across all identified areas to ensure surfaces were safe, intact, and cleanable. This included repairing, sanding, and sealing scratched or gouged doors, door jambs, and handrails to remove exposed wood and restore cleanable surfaces. Maintenance also completed deep cleaning of windowsills in the loft area. • For flooring, maintenance ensured safety by addressing uneven flooring between Room 218 and the fire doors and on 2/4/26 initiated long-term leveling through appropriate repair services. Stained carpets near Rooms 218–220 have been scheduled for professional shampooing; areas that do not respond to cleaning have been submitted for flooring replacement. • Full refinishing and restoration work requiring specialized services was initiated on 2/4/26 to ensure all surfaces including doors, handrails, and flooring are durable, uniform, and maintained in good repair. Prevention: • Maintenance added flooring integrity and loft cleanliness to Environmental Rounds check list completed monthly. • Maintenance will complete quarterly wall and door touch up days, documenting and reviewed in monthly environmental rounds. A. Monitor and Who: • Maintenance will monitor progress weekly until all repairs are completed, then monthly via documented Environmental Rounds. • The Administrator will review findings and sustained compliance through Quality Assurance Performance Improvement for at least three months. 4. Frequency: Weekly until full repair; then monthly PLUM KITCHENETTE & DINING A. Action • Maintenance repaired, refinished, and repainted the dining room doors to address scratches and gouges; removed the black plastic, patched and repainted the wall to match the room, repaired small holes to restore a cleanable surface, removed the plywood panel, installed a proper cabinet front, and replaced missing baseboards to ensure all surfaces are cleanable and in good repair. • The window screen reinstalled securely. • Maintenance cleaned ceiling vents and repaired ceiling holes. • Flooring around the kitchenette peninsula has been assessed, and safety mitigation was completed. Long-term leveling of the area was been initiated on 2/4/26 through appropriate repair services. B. Prevention 1. Kitchenette surfaces added to monthly Environmental Rounds checklist. 2. Staff instructed to report any wall, cabinet, or surface damage immediately through work orders C. Monitor and Who: • The Maintenance Director will monitor progress weekly until all repairs are completed, then monthly via documented Environmental Rounds. • The Administrator will review findings and sustained compliance through Quality Assurance Performance Improvement for at least three months. 4. Frequency: Weekly until full repair; then monthly FILLMORE– Doors, Handrails, Carpets A. Action • Maintenance repaired, refinished, and repainted the dining room doors to address scratches and gouges; removed the black plastic, patched and repainted the wall to match the room, repaired small holes to restore a cleanable surface, removed the plywood panel and installed a proper cabinet front, replaced missing baseboards to ensure all surfaces are cleanable and in good repair. • Full refinishing and restoration requiring specialized work beyond routine maintenance was initiated on 2/4/26 through qualified services to ensure all surfaces are durable, uniform, and maintained in good repair. • Carpet Cleaning- A floor specialist has shampooed all stained carpet between room 231 and the dining room. • Carpet areas that do not respond to professional cleaning have been flagged for flooring replacement. • All identified areas were made safe and cleanable immediately while permanent repairs or renovation proceed 2. Prevention • Interior surfaces including doors, walls, handrails, vents, and baseboards have been added to the monthly Environmental Rounds checklist to ensure regular monitoring. • Maintenance will complete quarterly wall and door touch-up days, with documentation reviewed in monthly Environmental Rounds. C. Monitor and Who: • The Maintenance Director will monitor progress weekly until all repairs are completed, then monthly via documented Environmental Rounds. • The Administrator will review findings and sustained compliance through Quality Assurance Performance Improvement for at least three months. 4. Frequency: Weekly until full repair; then monthly FILLMORE KITCHENETTE & DINING ROOM A. Action • Maintenance repaired, refinished, and repainted the dining room doors to address scratches and gouges; removed the black plastic, patched and repainted the wall to match the room, repaired small holes to restore a cleanable surface, removed the plywood panel and installed a proper cabinet front, replaced missing baseboards to ensure all surfaces are cleanable and in good repair. • The window screen reinstalled securely. • Maintenance cleaned ceiling vents and repaired ceiling holes. • Flooring was been assessed, and safety mitigation was completed. Long-term leveling of the area was initiated on 2/4/26 through appropriate repair services. • Maintenance cleaned the sticky backsplash and restored the surface condition and re-caulked the counter edges to address and ensure a sealed, cleanable surface. • Prevention • Kitchenette surfaces added to monthly Environmental Rounds checklist. • Staff instructed to report any wall, cabinet, or surface damage immediately through work orders. Monitor and Who: • The Maintenance Director will monitor progress weekly until all repairs are completed, then monthly via documented Environmental Rounds. • The Administrator will review findings and compliance through Quality Assurance Performance Improvement for at least three months. Frequency: • Weekly until full repair; then monthly

Based on interview and record review, it was determined the facility failed to ensure the move-in evaluation addressed all required elements for 1 of 1 sampled resident (#4) who was recently admitted to the facility. Findings include, but are not limited to: Resident 4 was admitted to the facility in 08/2023 with diagnoses including Alzheimer's disease. The move-in evaluation, completed on 07/10/23, failed to address the following required elements: * Cognition: decision making abilities; * Personality: including how the person copes with change or challenging situations; and * Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting and room temperature. The need to ensure all required elements were addressed in the move-in evaluation was discussed with Staff 1 (ALF Administrator), Staff 2 (RN Case Manager), Staff 3 (RN Case Manager) and Staff 5 (Ministry Administrator) on 08/23/23. They acknowledged the findings.

OAR 411-054-0034 (1-6) Resident Move-in and Eval: Res Evaluation For the resident noted in this citation, the move-in evaluation will include the required elements: * Cognition: decision making abilities * Personality: including how the person copes with change or challenging situations * Environmental factors that impact the resident's behavior including, but not limited to noise, lighting, and room temperature. Plan: 1. All evaluation forms have been revised, updated, and reviewed with RN to include required elements. 2. All existing evaluations have been updated to include required elements. 3. An audit will be conducted weekly on all move-in evaluations to ensure all required elements are included; monthly audits will be completed for three months following.    4. The ALF Administrator is responsible.

Based on interview and record review, it was determined the facility failed to ensure the MAR included resident-specific parameters for PRN medications for 1 of 3 sampled residents (#2) whose medications were reviewed. Findings include, but are not limited to: Resident 2 was admitted to the facility in 08/2020 with diagnoses including congestive heart failure. Resident 2's 08/01/23 through 08/20/23 MAR was reviewed, the following PRN medications lacked resident-specific parameters for administering: * PRN acetaminophen 325 mg and PRN hydromorphone 2 mg were both prescribed to treat pain; and * PRN acetaminophen 650 mg suppository and PRN acetaminophen 325 mg tablet were both prescribed to treat fever. The need to ensure MARs included clear parameters for multiple PRN medications which were prescribed to treat the same condition, parameters were followed as indicated, and MARs included all required components was discussed with Staff 1 (ALF Administrator), Staff 2 (RN Case Manager), Staff 3 (RN Case Manager) and Staff 5 (Ministry Administrator) on 08/23/23. They acknowledged the findings.

OAR 411-054-0055 (2) Systems: Medication Administration For the resident noted in this citation, PRN medications now includes resident-specific parameters for administering the following: * PRN acetaminophen 325 mg or PRN hydromorphone 2 mg to treat pain. * PRN acetaminophen 650 mg suppository or PRN acetaminophen 325 mg tablet to treat fever. Plan: 1. All MARs include clear parameters when a PRN is prescribed to treat the same condition, parameters will be followed as indicated, and MARs will include all required components. 2. The RN Case Manager will ensure the MARs include clear parameters for multiple PRN medications that are prescribed to treat the same condition, parameters will be followed as indicated. 3. An In service will be conducted with all medication trained staff regarding PRN medication administration. 4. An audit will be conducted weekly on all PRN parameters to ensure all required elements are included; monthly audits will be completed for three months following.   5. The ALF Administrator is responsible to ensure compliance with this requirement.

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medication used to treat resident behaviors had written, resident-specific parameters and non-pharmacological interventions were attempted and documented as not effective prior to administration of the medication for 1 of 1 sampled resident (#2). Findings include, but are not limited to: Resident 2 was admitted to the facility in 08/2020 with diagnoses including congestive heart failure. The resident was admitted to hospice in 01/2022. Review of the resident's 08/01/23 through 08/20/23 MAR and current physician orders revealed an order for lorazepam 0.5 mg, one tablet to be administered every 2 hours as needed for anxiety, restlessness or agitation. The facility administered lorazepam on twelve occasions between 08/01/23 and 08/20/23. The MAR lacked resident-specific parameters for staff describing how the resident presented behaviors such as agitation. There was no documentation of what non-pharmacological interventions were to be attempted prior to administration of the medication. In an interview on 08/22/23 with Staff 2 (RN Case Manager) and Staff 3 (RN Case Manager), they stated the parameter sheet for lorazepam was created by the hospice nursing team in 01/2022 and did not provide any additional information regarding behavior presentation or non-pharmacological interventions to attempt prior to medication administration. The need to ensure there were resident-specific descriptions of how the resident behaviors presented, and that non-pharmacological interventions were attempted and documented as not effective prior to administration of the medication, was discussed with Staff 1 (ALF Administrator), Staff 2, Staff 3 and Staff 5 (Ministry Administrator) on 08/22/23 and 08/23/23. They acknowledged the findings.

OAR 411-054-0055 (6) Systems: Psychotropic Medication For the resident noted in this citation, the MAR now indicates resident-specific parameters for staff describing how the resident presents behaviors such as agitation with clear instructions on how to document what non-pharmacological interventions were attempted prior to administration of the medication. Plan: 1. All PRN psychotropic medication used to treat resident behaviors will have written, resident-specific parameters and non-pharmacological interventions will be attempted and documented as not effective prior to administration of the medication. 2. The RN Case Manager will ensure the parameters include all noted resident-specifics. 3. An In service will be conducted with all medication trained staff regarding PRN medication administration. 4. All PRN psychotropic medications used will be audited weekly for two months to ensure there are resident-specific descriptions of how the resident behaviors present, and that non-pharmacological interventions (unless ordered differently by prescribing physician) will be attempted and documented as not effective prior to administration of the medication; monthly audits will be completed for three months following. 5. The ALF Administrator is responsible.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with Oregon Fire Code (OFC) and fire and life safety instruction to staff was provided and documented on alternate months. Findings include, but are not limited to: Review of fire drill and fire and life safety records for February 2023 through August 2023 identified the following: * There was no documented evidence fire and life safety instruction for staff had been consistently conducted and documented on alternate months; and * The facility had not documented residents being relocated or evacuated during fire drills, and there was no documentation of the escape route used, problems encountered, comments relating to residents who resisted or failed to participate in the drills, and number of occupants evacuated. The need to ensure the facility conducted and documented fire drills as required and provided fire and life safety instruction to staff on alternate months was reviewed with Staff 1 (ALF Administrator) and Staff 6 (Maintenance and Environmental Supervisor) on 08/23/23 at 1 pm. They acknowledged the findings.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety For the facility citation, the facility will ensure fire drills are conducted and documented as required and fire and life safety instruction to staff on alternate months will be provided. Plan: 1. Fire drills will be conducted in accordance with Oregon Fire Code with fire and life safety instruction given to staff documenting the occurrence on alternate months. 2. Facility fire drill forms have been updated to include documentation of: * Residents being relocated or evacuated during fire drills *Escape route used *Problems encountered *Comments relating to residents who resisted or failed to participate in the drills *Number of occupants evacuated 3. Fire drill forms will be reviewed after drills. 4. An annual training calendar of Life Safety instruction has been developed. 5. The ALF Administrator is responsible.

Based on interview and record review, it was determined the facility failed to ensure residents were re-instructed at least annually in fire and life safety in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety records for 02/23 through 08/23 were reviewed on 08/23/23. There was no documented evidence the facility provided annual fire and life safety training for residents that included: * General safety procedures; * Evacuation methods; * Responsibilities during fire drills; and * Designated meeting places outside the building or within the fire safe area in the event of an actual fire. The need to ensure residents were trained annually on the required fire and life safety topics was discussed with Staff 1 (ALF Administrator) and Staff 6 (Maintenance and Environmental Supervisor) on 08/23/23. The acknowledged the findings.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents For the facility citation, all residents will be trained annually on the required fire and life safety: *General safety procedures *Evacuation methods *Responsibilities during fire drills *Designated meeting places outside the building or within the fire safe area in the event of an actual fire Plan: 1. A written record of annual fire safety training, including content of the training will be completed with residents during annual evaluation and service planning meeting. 2. The annual evaluation form has been updated to include review of required elements. 3. A quarterly audit will be completed to ensure compliance. 4. The ALF Administrator is responsible.

The findings of the re-licensure survey conducted 08/21/23 through 08/23/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities 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 08/23/23, conducted 10/26/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.