OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs; This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide a daily program of social and recreational activities based upon individual and group interests, and physical, mental, and psychosocial needs. Findings include, but are not limited to: The facility consisted of a common area in the center of the building with four pods off of the common area. Those pods were named as follows: Alderwood, Birchwood, Cedarwood, and Dogwood. a. Observations during the survey from 08/25/25, to 08/28/25, showed a lack of scheduled and unscheduled activities provided for residents living in the memory care community. An activity calendar was provided, which noted scheduled activities for each day of the week. The activities noted for 08/26/25 included the following: * 9:00 am – Relax/Morning Walk (no location was noted); *10:15 am – BINGO (no location was noted); * 1:30 pm – Art/Music (no location was noted); * Movies and Popcorn (with no time and/or location listed); and * 4:00 pm – Games (no location was noted). During observations in Alderwood on 08/26/25 the above listed activities were not observed to have occurred and/or residents were not observed to have been invited to attend the above activities. Staff 19 (CG) stated the residents in Alderwood were “not very social”. Staff 19 stated the facility had an activities director who came to the pod to invite residents to activities when they occurred. Residents in Alderwood were observed sitting in the living room in recliners watching TV and/or movies throughout the day or sitting at tables in the dining room. Residents who were in their apartments were not approached for activity invitations during observations. The need to ensure the facility provided a daily program of social and recreational activities that were based on individual and group interests, and physical, mental, and psychosocial needs was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (RCC) on 08/28/25 at 11:00 am. They acknowledged the findings. b. Resident 2’s evaluation and service plan noted s/he was dependent on staff for transfers and escorts in a wheelchair to activities. S/he preferred independent activities, such as painting and puzzles, rather than group activities. S/he enjoyed the sunshine and preferred activities outside and community outings. During the survey from 08/25/25 through 08/28/25, Resident 2 was not observed participating in any outdoor activities, outings in the community, puzzles or painting. The need to ensure the facility provided a daily program of social and recreational activities that were based on individual interests was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (RCC) on 08/26/25 at 2:53 pm. They acknowledged the findings.

New Friends of Coos Bay will implement the following: 1. Activities calendar will be updated with activity locations and times. Staff will announce activities via Walkie-talkie and in-person walk-throughs of pods. Activity folders/boxes will be developed for individualized engagement options. 2. Activity calendars will all be updated for accuracy 3. Weekly monitoring will be done Activity Director and Executive Director will be responsible for monitoring

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs; This Rule is not met as evidenced by:

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. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to determine action or interventions, communicate the interventions to staff on each shift and monitor the interventions for effectiveness for 1 of 1 sampled resident (#3) who experienced a significant change of condition related to a pressure ulcer. Resident 3’s open wound worsened. Findings include, but are not limited to: Resident 3 moved into the MCC in 04/2022 with diagnoses including Alzheimer’s disease. The resident was identified during the acuity interview on 08/25/25 to have a pressure ulcer on his/her buttock. A progress note dated 06/24/25 noted “what appears to be an open area on the right gluteal fold”. Following the identification of the open area, the facility was applying barrier cream per standing orders. The open area was evaluated on 06/27/25 by the resident’s primary care provider (Medical Doctor). The provider identified the wound as a stage II decubitus ulcer (open wound) to the right gluteal fold and gave orders to cleanse wound, continue Secura protective cream and cover with foam dressing daily, reposition every two hours, and cushion or donut pillow to be used while the resident was in the wheelchair. There was no documented evidence the following interventions were communicated to staff or monitored for effectiveness: *Cleanse the wound and cover with foam dressing daily; *Reposition every two hours; and *Use of a cushion or donut pillow while the resident was in the wheelchair. On 07/18/25, Staff 2 (RN) completed an initial assessment noting “buttock wound is open, wound bed has greenish slough and is draining, Edges [sic] are defined, wound is pressure, not stageable due to slough”. Following the RN assessment, there was no documented evidence the facility reviewed the treatment interventions for effectiveness or determined new interventions. On 07/23/25, the resident was seen by his/her primary care provider (Medical Doctor) for follow-up on the decubitus ulcer (open wound). The provider’s assessment noted the decubitus ulcer (open wound) had worsened, progressing from stage II towards stage III, and the presence of significant skin breakdown. Provider placed an urgent referral for wound care and recommended the following interventions: * Use of a 1.5-inch-thick foam pad on the wheelchair to alleviate pressure; * Spend more time in bed or a recliner; and * Limit sitting in his/her wheelchair longer than one hour. There was no documented evidence the above treatment interventions were communicated to staff, implemented or weekly monitoring of the wound. On 07/30/25 the resident was seen at the emergency department (ED) for a wound on his/her right buttock. The wound was diagnosed as a pressure ulcer stage III. The resident was admitted to hospice services on 08/18/25. Antibiotic (metronidazole) treatment for an infection in the wound was initiated on 08/21/25. Review of hospice RN documentation of wound assessment dated 08/25/25 revealed the right gluteal fold wound was a stage IV pressure ulcer (open wound), indicating further worsening of the wound. The facility failed to determine interventions, communicate interventions to staff, implement wound treatments, monitor the interventions for effectiveness, and/or implement new interventions and monitor the wound, resulting in the wound worsening. Observation of wound care performed by a hospice nurse was made on 08/26/25 at 10:55 am. The Nurse Surveyor noted the wound open to right gluteal fold with no odor present. The resident was medicated by the MA or pain before wound care, however the resident expressed pain when the nurse touched the wound by making a moaning sound and moving his/her body away from the nurse. On 08/28/25 at 9:45 am, additional documentation of skin monitoring was requested. On 08/28/25 at 12:00 pm, Staff 2 and Staff 7 (Corporate Nurse/LPN) confirmed there was no additional documentation. The need to ensure the facility determined action or interventions, communicated the interventions to staff on each shift and monitored the interventions for effectiveness was discussed with Staff 1(ED), Staff 2, Staff 3 (RCC), Staff 7, Staff 29 (Corporate LPN), and Staff 30 (Chief People Officer) on 08/28/25 at 12:00 pm. They acknowledged the findings.

New Friends of Coos Bay will implement the following : 1. All staff will be Retrained on recognizing/reporting changes of condition. Implement standardized communication and ensure COC documentation occurs when required. RN has been hired. Staff will also attend an OCP-recognized COC class. COCs will be completed within 48 hours of the change and added to the Nurse duties on the communication board. 2. Executive Director, RN and RCC will check that alert chartings were opened with all new orders, incidents and changes in condition. The Executive Director and Nurse will close alerts when resolved. 3.Executive Director, RN, RCC and clinical support Nurse will check at least three times a week that staff are completing alert charting each shift. 4.Executive Director, RCC, RN and clinical support Nurse will be responsible to see that the corrections are completed and monitored.

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. This Rule is not met as evidenced by:

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. This Rule is not met as evidenced by: Based on interview and record review, it was determined that the facility failed to complete an RN assessment timely, including the documentation of interventions made as a result of the assessment and provide intermittent direct nursing services for 1 of 1 sampled resident (#3) who experienced a significant change of condition. Resident 3’s open wound worsened. Findings include, but are not limited to: Resident 3 moved into the MCC in 04/2022 with diagnoses including Alzheimer's disease. Resident 3's progress notes, dated 05/25/25 through 08/25/25 were reviewed and revealed the following: On 06/24/25, Staff 18 (MA) documented the identification of an open area on the right gluteal fold, which was communicated to management. On 06/27/25, Resident 3 was seen by his/her primary care provider (Medical Doctor), who documented the presence of a stage II decubitus ulcer (open wound) to the right gluteal fold. The presence of a stage II ulcer indicated a significant change of condition which required an RN assessment. An RN assessment was completed by Staff 2 (RN) on 07/18/25, 24 days following the documentation of the resident’s open area. The facility failed to ensure an RN assessment was completed timely following the identification of a stage II pressure ulcer on 06/27/25 and failed to ensure interventions were documented as a result of the RN assessment on 07/18/25 which noted the stage II pressure ulcer (open wound) had worsened to an unstageable pressure ulcer. In an interview with Staff 2 on 08/28/25 at 12:00 pm, she confirmed 07/18/25 was her first assessment of the area and noted the wound was an unstageable pressure ulcer. The RN assessment lacked documented treatment interventions made as a result of the assessment. Additionally, the facility failed to provide intermittent direct nursing services for Resident 3’s decubitus pressure ulcer (open wound) from 06/24/25 through 08/05/25 when nursing services were not available through hospice, home health, or a third-party referral. The need to ensure documented RN assessment was completed timely and documented interventions made as a result of the assessment was discussed with Staff 1(ED), Staff 2, Staff 3 (RCC), Staff 7 (Corporate Nurse/LPN), Staff 29 (Corporate LPN), and Staff 30 (Chief People Officer) on 08/28/25 at 12:00 pm. They acknowledged the findings. No further information was provided. Refer to C 270.

New Friends of Coos Bay will implement the following: 1. Refer to C270 All staff and nurses will be retrained on any skin concerns and will be documented right when noticed and documented in the communication area in our system for any and all skin issues. 2. All skin concerns will be communicated to the nurse the day it is noticed and documented. 3. The Executive Director, RN and RCC will check three times a week. 4. Executive Director, RN, RCC and clinical support Nurse will be responsible to see that the corrections are completed and monitored.

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. This Rule is not met as evidenced by:

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to maintain effective infection prevention and control protocols for multiple sampled and unsampled residents related to dining services. Findings include, but are not limited to: Multiple meals were observed in the Birchwood pod between 08/26/25 and 08/27/25. a. Staff were observed serving meals and beverages, touching residents, touching their own faces, repositioning wheelchairs, and assisting residents with feeding without changing their gloves or performing hand hygiene between all clean and dirty tasks. b. Direct care staff were observed serving meals and providing feeding assistance to sampled and unsampled residents without donning a protective barrier over potentially contaminated clothing. On 08/26/25 at 4:43 pm, Staff 9 (CG) and Staff 15 (CG) confirmed the only staff member who wore an apron during meal service was the person dishing up the food. The need to ensure the facility maintained infection prevention and control protocols to provide a safe, sanitary, and comfortable environment during meal service was reviewed on 08/28/25 at 11:16 am with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), Staff 7 (Corporate Nurse/LPN), Staff 29 (Corporate LPN), and Staff 30 (Chief People Officer). They acknowledged the findings.

New Friends of Coos Bay will implement the following: 1. Retrain staff on Hygiene and infection control practices. 2. Aprons and gloves will be worn when assisting a resident at meal time, and signs up to remind staff to wear them. ServSafe certification completed by Dietary Manager . Infection Control Specialist designated. Infection Control Team formed. 3. Daily by Executive Director and or person in charge 4. Executive Director, RCC and Dietary Manager will be responsible for monitoring daily.

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined that the facility failed to ensure treatment orders were carried out as prescribed for 1 of 1 sampled resident (# 3) whose treatment orders were reviewed. Findings include, but are not limited to: Resident 3 was admitted to the facility in 04/2022 with diagnoses including Alzheimer's disease. Resident 3's current physician's orders, MAR/TAR dated 06/01/25 through 08/25/25, and progress notes dated 05/25/25 through 08/26/25 were reviewed, and the following was identified: Resident 3 was seen by his/her primary care provider on 06/27/25 for a stage II decubitus ulcer to the right gluteal fold and was prescribed the following: * Daily wound cleansing and foam dressing applied, and to continue to use Secura protective skin cream with each dressing change and toileting. Review of the resident’s record during the survey on 08/25/25 through 08/28/25 revealed the above orders for daily wound cleansing and applying foam dressing were not transcribed to the MAR. Interview with Staff 7 (Corporate Nurse/LPN) and Staff 2 (RN) on 08/28/25 at 12:00 pm confirmed the facility did not have supplies to carry out the order as prescribed and Staff 7 confirmed she did not enter the order on the MAR. The need to ensure all treatments were carried out as prescribed was discussed with Staff 1 (ED), Staff 2, Staff 3 (RCC), Staff 7, Staff 29 (Corporate LPN), and Staff 30 (Chief People Officer) on 08/28/25 at 12:00 pm. They acknowledged the findings. No further documentation was provided.

New Friends of Coos Bay will implement the following: 1. All staff will be retrained on any and all orders that are received, they will be uploaded in the system, communicated and documented to the Nurse & Executive Director immediately, and supplies will be ordered and implemented if needed. All orders will be uploaded in a timely manner and documented when received. 2. Ensure orders above our scope are redirected promptly to contracted providers/outside agencies. Nurse will assist with expediting home health/hospice orders if needed. Orders will be reviewed and updated timely, documented on MAR and uploaded to medical records. Evaluate readmissions to determine if care Exceeds scope and initiates move-out if needed. Triple-check orders for accuracy 3. This will be checked daily for any new or changed orders. 4. Executive Director, RN, RCC and clinical support Nurse will be responsible to see that the corrections are completed and monitored.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by:

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure an RN, PT, or OT assessment was completed prior to the use of a supportive device with potentially restraining qualities, failed to document other less restrictive alternatives were evaluated prior to the use of the device, failed to instruct caregivers on the correct use and precautions related to the use of the device for 1 of 1 sampled resident (# 2) who used a supportive device with restraining qualities. Findings include, but are not limited to: Resident 2 had a twin size mattress approximately five inches in thickness on the floor laying parallel to his/her bed. During an interview and observation on 08/26/25 at 2:18 pm, Resident 2 was observed lying in bed with the twin mattress on the floor next to the bed. Resident 2 stated “that thing (pointing to the mattress on the floor), makes me afraid cause I can’t get my footing. I asked them to move it, but they don’t, so I just don’t get up. I want that thing out of here.” During an interview with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 08/26/25 at 2:53 pm, evaluations for Resident 2’s bed alarm and mattress on the floor were requested. Staff 2 stated, “there isn’t an evaluation for the mattress on the floor and if you are looking for an evaluation for the alarms, I can tell you now, you won’t find an evaluation for any residents that have an alarm on their bed or chair.” The need to ensure devices with potentially restraining qualities were assessed by an RN, PT or OT and evaluated on a quarterly basis was discussed with Staff 1, Staff 2, and Staff 3 on 08/26/25 at 2:53 pm. They acknowledged the findings.

New Friends of Coos Bay will implement the Following: 1. All staff have been trained on all devices with potential restraining qualities (tab alarms,bed alarms, mattresses on the floor, recliners with feet elevated). And an RN will complete the assessment prior to implementing any restraints. 2. Executive Director, RCC and RN will check residents rooms and areas to be sure no residents are using any kind of restraining things per OAR. All Staff will be trained on what is considered restraints. 3. This be will evaluated Weekly 4. Executive Director, RN, RCC and clinical support Nurse will be responsible to see that the corrections are completed and monitored.

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by:

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to conduct fire drills per OFC and to instruct staff in fire and life safety topics on alternate months from fire drills. Findings include, but are not limited to: Facility fire drill and fire and life safety records from 03/2025 to 08/2025 were requested and reviewed with Staff 1 (ED) and Staff 5 (Maintenance) on 08/26/25 at 8:50 am. The facility’s fire drill records lacked the following documentation: * Life safety training for staff on alternate months of the fire drills; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; and * Number of occupants evacuated and/or relocated to the point of safety. The need to ensure fire drills were conducted per OFC and staff were trained in fire and life safety procedures on alternate months from fire drills was discussed with Staff 1 and Staff 5 on 08/26/25 at 8:50 am They acknowledged the findings.

New Friends of Coos Bay will implement the Following: 1. Executive Director & Maintenance will be retrained on Fire drills & fire Life Safety per Rules. 2. Fire drill documentation will be updated to match state-provided format to be sure all documentation is documented. * Life safety training for staff on alternate months of the fire drills; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; and * Number of occupants evacuated and/or relocated to the point of safety. 3. The Executive Director will be checking monthly. 4. The Executive Director and Regional will be responsible to be sure the corrections are completed and monitored.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by:

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. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the environment was clean and in good repair. Findings include, but are not limited to: The facility consisted of a common area in the center of the building with four pods off the common area. Those pods were named as follows: Alderwood, Birchwood, Cedarwood, and Dogwood. The interior of the building was observed on 08/25/25 at 1:38 pm through 3:35 pm and again on 08/27/25 at 10:15 am. The following areas needed cleaning and/or repair: Common Area: * Coffee table in front of the couches in the entry had multiple scratches; and * Chairs outside of the RCC office and near the piano were missing varnish and/or had stained seats. Alderwood: * Table in the entry/common area had wood chipped and/or missing; * Trim throughout had black scuff marks and/or was chipped; * Uncovered garbage can in the kitchenette; * Vents in the ceiling outside of A-10 had dust build up; * Dining room chairs had worn seats with cracked vinyl; and * Exit door to the courtyard had chipped paint. Birchwood: * Exit doors to the courtyard had chipped paint; * Sink in B-14 was slow to drain; and * Trim throughout had black scuff marks and/or was chipped. Cedarwood: * Table in the common area was marked/chipped; * Chairs in the common area had worn and/or stained seats; * Trim throughout had black scuff marks and/or was chipped; * Faucet in room 12 was installed with hot and cold reversed; * Dining room chairs had worn seats with cracked vinyl; and * Exit door to the courtyard had chipped paint. Dogwood: * Table in the common area was marked/chipped; * Chairs in the common area had worn and/or stained seats; * Dining room chairs had worn seats with cracked vinyl; and * Exit door to the courtyard had chipped paint. The areas needing cleaning and/or repair were shown to and discussed with Staff 1 (ED) and Staff 5 (Maintenance) on 08/27/25 at 10:15 am. They acknowledged the findings.

New Friends of Coos Bay will implement the Following: 1. All areas of concern below will be cleaned, repaired or replaced. Common Area: * Coffee table in front of the couches in the entry had multiple scratches; and * Chairs outside of the RCC office and near the piano were missing varnish and/or had stained seats. Alderwood: * Table in the entry/common area had wood chipped and/or missing; * Trim throughout had black scuff marks and/or was chipped; * Uncovered garbage can in the kitchenette; * Vents in the ceiling outside of A-10 had dust build up; * Dining room chairs had worn seats with cracked vinyl; and * Exit door to the courtyard had chipped paint. Birchwood: * Exit doors to the courtyard had chipped paint; * Sink in B-14 was slow to drain; and * Trim throughout had black scuff marks and/or was chipped. Cedarwood: * Table in the common area was marked/chipped; * Chairs in the common area had worn and/or stained seats; * Trim throughout had black scuff marks and/or was chipped; * Faucet in room 12 was installed with hot and cold reversed; * Dining room chairs had worn seats with cracked vinyl; and * Exit door to the courtyard had chipped paint. Dogwood: * Table in the common area was marked/chipped; * Chairs in the common area had worn and/or stained seats; * Dining room chairs had worn seats with cracked vinyl; and * Exit door to the courtyard had chipped paint. 2. We will provide a routine maintenance log to be completed as scheduled 3. Upon scheduled maintenance days, and weekly. 4. The Maintenance Director and Executive Director will be responsible to be sure the corrections are completed and monitored.

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. This Rule is not met as evidenced by:

OAR411-004-0020(1)(d) Individual Rights Settings Right to Freedom (1) Residential and non-residential HCB settings must have all of the following qualities: (d) The setting ensures the individual the right to freedom from restraints, except in accordance with the standards set forth in ORS 443.739, OAR chapters 309 and 411, 1915(c) HCBS Waivers, 1915(i) State Plan HCBS, or 1915(k) Community First Choice (K State Plan Option). When the right to freedom from restraints must be limited due to a threat to the health and safety of an individual or others, an individually-based limitation as described in OAR 411-004-0040 must apply in any residential or non-residential setting. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure each individual was free from restraints. Findings include, but are not limited to: Refer to C340.

Refer to C340

OAR411-004-0020(1)(d) Individual Rights Settings Right to Freedom (1) Residential and non-residential HCB settings must have all of the following qualities: (d) The setting ensures the individual the right to freedom from restraints, except in accordance with the standards set forth in ORS 443.739, OAR chapters 309 and 411, 1915(c) HCBS Waivers, 1915(i) State Plan HCBS, or 1915(k) Community First Choice (K State Plan Option). When the right to freedom from restraints must be limited due to a threat to the health and safety of an individual or others, an individually-based limitation as described in OAR 411-004-0040 must apply in any residential or non-residential setting. This Rule is not met as evidenced by:

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure each individual had privacy in his or her own unit for 4 of 4 sampled residents (#s 1, 2, 3, and 4) and multiple unsampled residents who shared bathrooms. Findings include, but are not limited to: Observations of the four pods of the MCC were conducted between 08/25/25 and 08/28/25. Residents 1, 2, 3, 4, and multiple unsampled residents were noted to share a bathroom. The bathrooms had two sliding pocket doors with each door opening to a different resident unit. Both pocket doors had the capability to lock from inside the bathroom; however, each door could be unlocked without a key by turning the locking mechanism from the resident’s room. Therefore, each individual was not ensured privacy when using his/her shared restroom. In an interview with Staff 1 (ED) and Staff 5 (Maintenance) on 08/26/25 at 3:20 pm and 08/27/25 at 10:15 am, it was confirmed bathrooms with pocket doors shared between two units had a locking mechanism that could be opened without a key from each resident’s room. The need to ensure privacy in individual resident units was reviewed on 08/28/25 at 12:00 pm with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), Staff 7 (Corporate Nurse/LPN), Staff 29 (Corporate LPN), and Staff 30 (Chief People Officer). They acknowledged the findings.

New Friends of Coos Bay will implement the Following: 1. Executive Director & Maintenance have been trained on rules of privacy locks and bathrooms. 2. All shared restrooms will have a key entry lock installed to ensure privacy when using the shared restroom. 3. Executive Director and Maintenance will check monthly, 4. Executive Director and Maintenance will be responsible to see that the corrections are completed and Monitored

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by:

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their individual units. Findings include, but are not limited to: The service plans for Residents 1, 2, 3, and 4 were reviewed between 08/25/25 and 08/28/25 and revealed the four sampled residents had not been given keys to their rooms. During an interview on 08/26/25 at 2:53 pm, Staff 1 (ED) reported “most of the residents don’t have a key, they can’t use it. If the family doesn’t want it, then we don’t give one.” The need to ensure all residents were provided keys to their individual units was reviewed on 08/28/25 at 12:00 pm with Staff 1, Staff 2 (RN), Staff 3 (RCC), Staff 7 (Corporate Nurse/LPN), Staff 29 (Corporate LPN), and Staff 30 (Chief People Officer). They acknowledged the findings.

New Friends of Coos Bay will implement the following: 1.Executive Director and RCC were retrained on the need to ensure all residents were provided keys to their individual units and documented. All residents and guardians will be offered a key and it will be documented and put into their service plan per rule. All new move-ins will be using the new version of the Assessment , so the key assessment is automatically on the service plan. 3. With each Move in, and careplan done. 4. The Executive Director and RCC will be responsible for monitoring the corrections to be sure they are completed.

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by:

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. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C242, C295, C420 and C513.

Refer to C242, C295, C420 and C513.

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. This Rule is not met as evidenced by:

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C270, C280, C303, and C340.

Refer to C270, C280, C303, and C340.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: