OAR 411-054-0105
Inspections and Investigations

(1) The facility must cooperate with Department personnel in inspections, complaint investigations, planning for resident care, application procedures, and other necessary activities.
(a) Records must be made available to the Department upon request. Department personnel must have access to all resident and facility records and may conduct private interviews with residents. Failure to comply with this requirement shall result in regulatory action.
(b) The State Long Term Care Ombudsman must have access to all resident and facility records that relate to an investigation. Certified Ombudsman volunteers may have access to facility records that relate to an investigation and access to resident records with written permission from the resident or guardian.
(c) The State Fire Marshal or authorized representative must be permitted access to the facility and records pertinent to resident evacuation and fire safety.
(2) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full 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 visit and conduct an inspection of the kitchen and other areas where food is prepared for residents.
(b) Subsection (a) will not go into effect until January 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.
(3) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation.
(4) A copy of the most current inspection report and any conditions placed upon the license must be posted with the facility’s license in public view near the main entrance to the facility.
(5) ABUSE OR RULE VIOLATION. Upon completion of substantiation of abuse or rule violation, the Division shall immediately provide written notification to the facility.
(a) WRITTEN NOTICE. The written notice shall:
(A) Explain the nature of each allegation;
(B) Include the date and time of each occurrence;
(C) For each allegation, include a determination of whether the allegation is substantiated, unsubstantiated, or inconclusive;
(D) For each substantiated allegation, state whether the violation was abuse or another rule violation;
(E) Include a copy of the complaint investigation report;
(F) State that the complainant, any person reported to have committed wrongdoing, and the facility have 15 days to provide additional or different information; and
(G) For each allegation, explain the applicable appeal rights available.
(b) APPORTIONMENT. If the Department determines there is substantiated abuse, the Department may determine that the facility, an individual, or both the facility and an individual are responsible for the abuse. In determining responsibility, the Department shall consider intent, knowledge and ability to control, and adherence to professional standards as applicable.
(A) FACILITY. Examples of when the Department shall determine the facility is responsible for the abuse include but are not limited to:
(i) Failure to provide minimum staffing in accordance with these rules without reasonable effort to correct;
(ii) Failure to check for or act upon relevant information available from a licensing board;
(iii) Failure to act upon information from any source regarding a possible history of abuse by any staff or prospective staff;
(iv) Failure to adequately provide oversight, training, or orientation of staff;
(v) Failure to allow sufficient time to accomplish assigned tasks;
(vi) Failure to provide adequate services;
(vii) Failure to provide adequate equipment or supplies; or
(viii) Failure to follow orders for treatment or medication.
(B) INDIVIDUAL. Examples of when the Department shall determine the individual is responsible for the abuse include but are not limited to:
(i) Intentional acts against a resident including assault, rape, kidnapping, murder, sexual abuse, or verbal or mental abuse;
(ii) Acts contradictory to clear instructions from the facility, unless the act is determined by the Department to be caused by the facility as identified in paragraph (A) above;
(iii) Callous disregard for resident rights or safety; or
(iv) Intentional acts against a resident’s property (e.g., theft, misuse of funds).
(C) An individual may not be considered responsible for the abuse if the individual demonstrates the abuse was caused by factors beyond the individual’s control. “Factors beyond the individual’s control” are not intended to include such factors as misuse of alcohol or drugs or lapses in sanity.
(c) DUE PROCESS RIGHTS.
(A) NON-NURSING ASSISTANT. The written notice in cases of substantiated abuse by a person other than a nursing assistant shall explain the person’s right to:
(i) File a petition for reconsideration pursuant to OAR 137-004-0080 (Reconsideration — Orders in Other than Contested Case); and
(ii) Petition for judicial review pursuant to ORS 183.484 (Jurisdiction for review of orders other than contested cases).
(B) NURSING ASSISTANT. The written notice in cases of substantiated abuse by a nursing assistant shall explain:
(i) The Department’s intent to enter the finding of abuse into the Nursing Assistant Registry following the procedure set out in OAR 411-089-0140 (Letters of Determination); and
(ii) The nursing assistant’s right to provide additional information and request a contested case hearing as provided in OAR 411-089-0140 (Letters of Determination).
(C) FACILITY. The written notice shall advise the facility of the facility’s due process rights as appropriate.
(d) DISTRIBUTION.
(A) The written notice shall be mailed to the facility, any person reported to have committed wrongdoing, the complainant (if known), and the Department or Type B AAA office; and
(B) A copy of the written notice shall be placed in the Department’s facility complaint file.
(6) Upon receipt of a notice of abuse for victims covered by ORS 430.735 (Definitions for ORS 430.735 to 430.765), the facility shall provide written notice of the findings to the person found to have committed abuse, the residents of the facility, the residents’ case managers, and the residents’ guardians.

Source: Rule 411-054-0105 — Inspections and Investigations, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=411-054-0105 (accessed May 26, 2025).

411–054–0000
Purpose 411–054–0005
Definitions 411–054–0010
Licensing Standard 411–054–0012
Requirements for New Construction or Initial Licensure 411–054–0013
Application for Initial Licensure and License Renewal 411–054–0016
New Applicant Qualifications 411–054–0019
Change of Ownership or Management 411–054–0025
Facility Administration 411–054–0026
Notice to Potential Residents 411–054–0027
Resident Rights and Protections 411–054–0028
Abuse Reporting and Investigation 411–054–0030
Resident Services 411–054–0034
Resident Move-In and Evaluation 411–054–0036
Service Plan — General 411–054–0038
Individually-Based Limitations 411–054–0040
Change of Condition and Monitoring 411–054–0045
Resident Health Services 411–054–0050
Infection Prevention and Control 411–054–0055
Medications and Treatments 411–054–0060
Restraints and Supportive Devices 411–054–0065
Administrator Qualifications and Requirements 411–054–0070
Staffing Requirements and Training 411–054–0080
Involuntary Move-out Criteria 411–054–0085
Refunds and Financial Management 411–054–0090
Fire and Life Safety 411–054–0093
Emergency and Disaster Planning 411–054–0100
Exceptions and Waivers 411–054–0105
Inspections and Investigations 411–054–0106
Regulatory Framework 411–054–0110
Conditions 411–054–0120
Civil Penalties 411–054–0130
Non-Renewal, Denial, Suspension or Revocation of License 411–054–0133
Temporary Manager 411–054–0135
Criminal Penalties 411–054–0140
Additional Authority 411–054–0200
Residential Care Facility Building Requirements 411–054–0300
Assisted Living Facility Building Requirements 411–054–0320
Quality Measurement Program and Council

May 26, 2025

Rule 411-054-0105's source at or​.us